Ovid: Blueprints Psychiatry

Authors: Murphy, Michael J.; Cowan, Ronald L. Title: Blueprints Psychiatry, 5th Edition

Copyright ©2009 Lippincott Williams & Wilkins

> Front of Book > Abbreviations

Abbreviations

Abbreviations
AA

Alcoholics Anonymous

ABG

Arterial blood gas

ACLS

Advanced cardiac life support

ADHD

Attention-deficit/hyperactivity disorder

ASP

Antisocial personality disorder

BAL
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Ovid: Blueprints Psychiatry

Blood alcohol level

BID

Twice daily

CBC

Complete blood count

CBT

Cognitive-behavioral therapy

CNS

Central nervous system

CO2

Carbon dioxide

CPR

Cardiopulmonary resuscitation

CSF

Cerebrospinal fluid

CT

Computerized tomography

CVA

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Ovid: Blueprints Psychiatry

Cerebrovascular accident

DBT

Dialectical behavior therapy

DID

Dissociative identity disorder

DT

Delirium tremens

ECT

Electroconvulsive therapy

EEG

Electroencephalogram

ECG

Electrocardiogram

EPS

Extrapyramidal symptoms

EW

Emergency ward

FBI

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Ovid: Blueprints Psychiatry

Federal Bureau of Investigation

5HIAA

5-hydroxy indoleacetic acid

5HT

5-hydroxy tryptamine

GABA

Gamma-amino butyric acid

GAD

Generalized anxiety disorder

GHB

Gamma-hydroxybutyrate

GI

Gastrointestinal

HPF

High power field

HIV

Human immunodeficiency virus

ICU

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Ovid: Blueprints Psychiatry

Intensive care unit

IM

Intramuscular

IPT

Intrapersonal therapy

IQ

Intelligence quotient

IV

Intravenous

LP

Lumbar puncture

LSD

Lysergic acid diethylamine

MAOI

Monoamine oxidase inhibitor

MCV

Mean corpuscular volume

MDMA

Ecstasy
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Ovid: Blueprints Psychiatry

MR

Mental retardation

MRI

Magnetic resonance imaging

NIDA

National Institute on Drug Abuse

NMS

Neuroleptic malignant syndrome

OCD

Obsessive-compulsive disorder

PCA

Patient controlled analgesia

PMN

Polymorphonuclear leukocytes

PO

By mouth

PTSD

Posttraumatic stress disorder

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Ovid: Blueprints Psychiatry

QD

Each day

REM

Rapid eye movement

SES

Socioeconomic status

SSRI

Selective serotonin reuptake inhibitor

TD

Tardive dyskinesia

T4

Tetra-iodo thyronine

T3

Tri-iodo thyronine

TCA

Tricyclic antidepressant

TID

Three times daily

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%20Abbreviations.htm (8 of 8) [30/01/2009 06:20:48 ‫]ﻡ‬ ..Ovid: Blueprints Psychiatry TSH Thyroid-stimulating hormone WBC White blood cell count WISC-R Wechsler Intelligence Scale for Children—Revised file:///C|/Documents%20and%20Settings/ASUS/My%..Blueprints%20Psychiatry/0.

... Ronald L. Title: Blueprints Psychiatry. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Front of Book > Authors Authors Michael J.vi Contributors file:///C|/Documents%20and%20Settings/ASUS/My%. PhD Director Psychiatric Neuroimaging Program Assistant Professor of Psychiatry Assistant Professor of Radiology and Radiological Sciences Vanderbilt University School of Medicine Nashville. Cowan MD.%20Authors. Michael J. MPH Medical Director Vanderbilt Psychiatric Hospital Assistant Professor of Psychiatry Vanderbilt University School of Medicine Nashville. Murphy MD. Tennessee Ronald L.Ovid: Blueprints Psychiatry Authors: Murphy.older/Blueprints%20Psychiatry/0.htm (1 of 2) [30/01/2009 06:20:49 ‫]ﻡ‬ . Cowan. Tennessee P.

%20Authors.htm (2 of 2) [30/01/2009 06:20:49 ‫]ﻡ‬ . Vanderbilt University Nashville. Tennessee Faculty Advisor Lloyd I. Tennessee Vidya Raj MD Resident in Adult Psychiatry. Vanderbilt University Nashville.Ovid: Blueprints Psychiatry Michelle Brooks MD Resident in Adult Psychiatry..older/Blueprints%20Psychiatry/0. Office of Mental Health Albany.. New York file:///C|/Documents%20and%20Settings/ASUS/My%. Sederer MD Medical Director.

Ronald L.htm (1 of 2) [30/01/2009 06:20:51 ‫]ﻡ‬ . This new edition reflects changes in response to user feedback. We cover each major diagnostic category.Ovid: Blueprints Psychiatry Authors: Murphy. Many students have reported that the book is also useful for the successful completion of the core and advanced psychiatry clerkships. legal issues.. Before Blueprints. and special situations that are unique to the field. 25% more USMLE study questions. The structure of the book mirrors the major concepts and therapeutics of modern psychiatric practice.. We have kept the content current by repeated updates and revisions of the book while retaining a balance between comprehensiveness and brevity. Michael J. Title: Blueprints Psychiatry. and a Neural Basis section for each major diagnostic category. Cowan. each major class of somatic and psychotherapeutic treatment. we felt that review books were either too cursory to be adequate or too detailed in their coverage for busy readers with little free time.%20Preface.older/Blueprints%20Psychiatry/0. In this edition we have included new images.. We believe that the book provides a good overview of the field that the student should supplement with more in-depth reading. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Front of Book > Preface Preface Blueprints in Psychiatry was conceived by a group of recent medical school graduates who saw that there was a need for a thorough yet compact review of psychiatry that would adequately prepare students for the USMLE yet would be digestible in small pieces that busy residents can read during rare moments of calm between busy hospital and clinical responsibilities. We recommend that those file:///C|/Documents%20and%20Settings/ASUS/My%.

MPH file:///C|/Documents%20and%20Settings/ASUS/My%. You never know when you'll have a free moment to review for the boards! Michael J. We hope that Blueprints in Psychiatry fits as neatly into your study regimen as it fits into your backpack or briefcase. Murphy MD.htm (2 of 2) [30/01/2009 06:20:51 ‫]ﻡ‬ ..Ovid: Blueprints Psychiatry preparing for USMLE read the book in chapter order but cross reference when helpful between diagnostic and treatment chapters.older/Blueprints%20Psychiatry/0..%20Preface.

Disability is due in part to the extreme degree of social and occupational dysfunction associated with these disorders. Schizophrenia is currently considered a neurodevelopmental illness. Specific psychotic symptoms include delusions.Psychotic Disorders Chapter 1 Psychotic Disorders Psychotic disorders are a collection of disorders in which psychosis.Ovid: Blueprints Psychiatry Authors: Murphy. their psychosis is secondary to a mood disorder. file:///C|/Documents%20and%20Settings/ASUS/M. These patients do not have a primary psychotic disorder. predominates the symptom complex. The diagnoses described below are among the most severely disabling of mental disorders. Table 1-1 lists the Diagnostic and Statistical Manual of Mental Disorders. with enlarged cerebral ventricles is a hallmark finding./Chapter%201%20-%20Psychotic%20Disorders. hallucinations. 4th edition (DSM-IV) classification of the psychotic disorders.. It is important to understand that psychotic disorders are different from mood disorders with psychotic features.. Reduced regional brain volume. NEURAL BASIS Much of our understanding of the neural basis for psychotic disorders is based in research on schizophrenia. ideas of reference. Title: Blueprints Psychiatry. defined as a gross impairment in reality testing. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 1 . Brain volume is reduced in limbic regions including amygdala. rather. and disorders of thought. hippocampus. Michael J.htm (1 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . Ronald L. Cowan. Patients can present with a severe episode of depression and have delusions or with a manic episode with delusions and hallucinations..

Altered dopamine function is strongly implicated in positive and negative symptoms of schizophrenia.2 ▪ TABLE 1-1 Psychotic Disorders file:///C|/Documents%20and%20Settings/ASUS/M. γ-aminobutyric acid. urban living. neurocognitive abnormalities such as low premorbid intelligence quotient (IQ) or early childhood neurodevelopmental difficulties. migration to a different culture. glutamate.. although theories exist for this finding. Schizophrenia is diagnosed disproportionately among the lower socioeconomic classes. SCHIZOPHRENIA Schizophrenia is a disorder in which patients have psychotic symptoms and social or occupational dysfunction that persists for at least 6 months.htm (2 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . EPIDEMIOLOGY Schizophrenia affects 1% of the population. and cannabis use (especially in susceptible individuals). RISK FACTORS Risk factors for schizophrenia include genetic risk factors (family history). The prefrontal cortex microanatomy is altered. Women are more likely to have a “first break” later in life. prenatal and perinatal factors such as difficulties or infections during maternal pregnancy or delivery.. and the other monoamine neurotransmitters are also likely affected. none has been substantiated. P. Thalamic and basal ganglia regions are also affected. The typical age of onset is the early 20s for men and the late 20s for women. about one-third of women have an onset of illness after age 30./Chapter%201%20-%20Psychotic%20Disorders.Ovid: Blueprints Psychiatry and parahippocampal gyrus. in fact.

There is a clear inheritable component.htm (3 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . ▪ TABLE 1-2 Positive and Negative Symptoms of Schizophrenia file:///C|/Documents%20and%20Settings/ASUS/M. No one finding or theory to date suffices to explain the etiology and pathogenesis of this complex disease. This theory is consistent with the efficacy of antipsychotics (which block dopamine receptors) and the ability of drugs (such as cocaine or amphetamines) that stimulate dopaminergic activity to induce psychosis. and schizophrenia does occur in families with no history of the disease. Postmortem studies have also shown higher numbers of dopamine receptors in specific subcortical nuclei of those with schizophrenia than in those with normal brains./Chapter%201%20-%20Psychotic%20Disorders... The most notable theory is the dopamine hypothesis. More recent studies have focused on structural and functional abnormalities through brain imaging of patients with schizophrenia and control populations. but familial incidence is sporadic. Schizophrenia is widely believed to be a neurodevelopmental disorder.Ovid: Blueprints Psychiatry Schizophrenia Schizophreniform disorder Schizoaffective disorder Brief psychotic disorder Shared psychotic disorder Delusional disorder ETIOLOGY The etiology of schizophrenia is unknown. which posits that schizophrenia is due to hyperactivity in brain dopaminergic pathways.

visual. repetitivestereotyped behavior Adapted from Andreasen NC.. delusions. as well as because some medications seem to be more effective in treating negative symptoms. grandiose. agitation). thought insertion. by a pattern of social and occupational deterioration.” including poverty of speech and of speech content in response to a question Asociality Positive Symptoms Hallucinations Delusions Auditory. and behaviors (e. interests. little sexual interest CLINICAL MANIFESTATIONS History and Mental Status Examination Schizophrenia is a disorder characterized by symptoms that have been termed positive and negative symptoms.. perceptions. Washington.Ovid: Blueprints Psychiatry Negative Symptoms Affective flattening Alogia Decreased expression of emotion. DC: American Psychiatric Publishing. hallucinations../Chapter%201%20-%20Psychotic%20Disorders. 2001. persecutory. Introductory Textbook of Psychiatry. or olfactory hallucinations. negative symptoms are characterized by the absence of normal social and mental functions (e. paranoid. The positive versus negative distinction was made in a nosologic attempt to identify subtypes of schizophrenia.g. patients often exhibit both positive and negative symptoms at the file:///C|/Documents%20and%20Settings/ASUS/M. and poor selfcare). lack of motivation. ideas of reference.htm (4 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . Clinically. activities. isolation. thought withdrawal Bizarre behavior Aggressive/agitated. 3rd ed. religious. thought broadcasting. odd social behavior. Positive symptoms are characterized by the presence of unusual thoughts. impaired intimacy.. and by persistence of the illness for at least 6 months. such as lack of expressive gestures Literally “lack of words. odd clothing or appearance. Black DW. tactile.g. voices that are commenting Often described by content. anergia. Few friends.

There must also be social or occupational dysfunction. Inquiring about the premorbid history may help to distinguish schizophrenia from a psychotic illness secondary to mania or drug ingestion. DC: American Psychiatric Publishing.e. social withdrawal./Chapter%201%20-%20Psychotic%20Disorders. delusions. file:///C|/Documents%20and%20Settings/ASUS/M. disorganized speech.. affect not flat Motoric immobility or excessive. or thought disorder Adapted from Andreasen NC. or negative symptoms. not catatonic Delusions. and unusual (although not frankly delusional) thinking.Ovid: Blueprints Psychiatry same time. disorganized speech. catatonic behavior. The patient must be ill for at least 6 months. To make the diagnosis. hallucinations. grossly disorganized or catatonic (mute or posturing) behavior. criteria not met for paranoid. 2001. etc. now resolved (i. P. maintenance of a rigid posture. no prominent delusions. or disorganized Met criteria for schizophrenia.. no hallucinations. The prodrome of schizophrenia includes poor social skills. disorganized behavior. Washington. two (or more) of the following criteria must be met: hallucinations. Table 1-2 lists common positive and negative symptoms.3 ▪ TABLE 1-3 Subtypes of Schizophrenia Paranoid Catatonic Paranoid delusions. Introductory Textbook of Psychiatry.htm (5 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . Black DW. purposeless motor activity. flat or inappropriate affect. hallucinations. negative symptoms.. echolalia Disorganized Undifferentiated (probably most common) Residual Disorganized speech.) but residual negative symptoms or attenuated delusions. Patients with schizophrenia generally have a history of abnormal premorbid functioning. frequent auditory hallucinations. 3rd ed. catatonic.

social and vocational skills training. Differential Diagnosis The differential diagnosis of an acute psychotic episode is broad and challenging (Table 1-4). Diagnostic Evaluation The diagnostic evaluation for schizophrenia involves a detailed history. including stable reality-oriented psychotherapy. Medical causes. psychoeducation. and laboratory examination. a mood disorder with psychotic features. The subtypes of schizophrenia are useful as descriptors but have not been shown to be reliable or valid. should be ruled out. Table 1-3 describes these subtypes. Once a medical or substance-related condition has been ruled out./Chapter%201%20-%20Psychotic%20Disorders. These medications are used to treat acute psychotic episodes and to maintain patients in remission or with long-term illness. and residual. prior depression. and recent hospital discharge. such as neuroendocrine abnormalities and psychostimulant abuse or dependence. Psychosocial treatments. MANAGEMENT Antipsychotic agents are primarily used in treatment. and attention to details of living situation (housing. or a personality disorder.Ovid: Blueprints Psychiatry Patients with schizophrenia are at high risk for suicide. undifferentiated. physical.. Approximately one-third will attempt suicide. a delusional disorder. disorganized. the task is to differentiate schizophrenia from a schizoaffective disorder.htm (6 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . Antipsychotic medications are discussed in Chapter 11. and 10% will complete suicide. Complications of schizophrenia include those related to antipsychotic file:///C|/Documents%20and%20Settings/ASUS/M. age younger than 30 years. Risk factors for suicide include male gender. and such brain insults as tumors or infection. chronic course. daily activities) are critical to the long-term management of these patients. catatonic. Combinations of several classes of medications are often prescribed in severe or refractory cases.. family support. roommates. DSM-IV recognizes five subtypes of schizophrenia: paranoid. preferably including brain magnetic resonance imaging (MRI).

5% to 0. schizophreniform) Drug Abuse and Withdrawal Alcohol withdrawal Amphetamines and cocaine Prescription Drugs Anticholinergic agents Phencyclidine (PCP) and hallucinogens Sedative-hypnotic withdrawal Depression with psychotic features Mania file:///C|/Documents%20and%20Settings/ASUS/M.g. Once diagnosed. must persist for some time in the absence of any mood syndrome. Their psychotic symptoms. P.. Age of onset is similar to schizophrenia (late teens to early 20s). a history of head trauma./Chapter%201%20-%20Psychotic%20Disorders. schizophrenia is a long-term remitting/relapsing disorder with impaired interepisode function. Poorer prognosis occurs with early onset.4 ▪ TABLE 1-4 Causes of Acute Psychotic Syndromes Major Psychiatric Disorders Acute exacerbation of schizophrenia Atypical psychoses (e. however..htm (7 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ .. EPIDEMIOLOGY Lifetime prevalence is estimated at 0.8%. secondary consequences of poor healthcare and impaired ability to care for oneself. and increased rates of suicide. or comorbid substance abuse.Ovid: Blueprints Psychiatry medications. SCHIZOAFFECTIVE DISORDER Patients with schizoaffective disorder have psychotic episodes that resemble schizophrenia but with prominent mood disturbances.

Ovid: Blueprints Psychiatry Digitalis toxicity Glucocorticoids and adrenocorticotropic hormone(ACTH) Isoniazid L-DOPA (3./Chapter%201%20-%20Psychotic%20Disorders.and hyperthyroidism Paraneoplastic syndromes (limbic encephalitis) Infectious viral encephalitis Lupus cerebritis Neurosyphilis Stroke Wilson's disease Heavy metals file:///C|/Documents%20and%20Settings/ASUS/M..and hypercalcemia Hypo..4-dihydroxy-L-phenylalanine) and other dopamine agonists Nonsteroidal anti-inflammatory agents Withdrawal from monoamine oxidase inhibitors (MAOIs) Other Toxic Agents Carbon disulfide Neurologic Causes AIDS encephalopathy Brain tumor Complex partial seizures Early Alzheimer's or Pick's disease Huntington's disease Hypoxic encephalopathy Metabolic Causes Acute intermittent porphyria Cushing's syndrome Early hepatic encephalopathy Nutritional Causes Niacin deficiency (pellagra) Thiamine deficiency (Wernicke-Korsakoff syndrome) Vitamin B12 deficiency Hypo.htm (8 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ .

. or simply a superimposed mood disorder and psychotic disorder. There are two subtypes of schizoaffective disorder recognized in the DSM-IV. et al.Ovid: Blueprints Psychiatry From Rosenbaum JF. Hyman SE. which are determined by the nature of the mooddisturbance episodes. a variant of a mood disorder.5 major mood disturbance. ETIOLOGY The etiology of schizoaffective disorder is unknown.htm (9 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . Handbook of Psychiatric Drug Therapy. RISK FACTORS Risk factors for schizoaffective disorder are not well established but likely overlap with those of schizophrenia and affective disorders. Arana GW. It may be a variant of schizophrenia. 5th ed./Chapter%201%20-%20Psychotic%20Disorders. such as a manic or depressive episode. depressive and bipolar. 2005.. Mood disturbances need to be present for a substantial portion of the illness. CLINICAL MANIFESTATIONS History and Mental Status Examination Patients with schizoaffective disorder have the typical symptoms of schizophrenia and coincidentally a P. They must also have periods of illness in which they have psychotic symptoms without a major mood disturbance. a distinct psychotic syndrome. Diagnostic Evaluation The diagnostic evaluation for schizoaffective disorder is similar to other psychiatric conditions and involves a detailed file:///C|/Documents%20and%20Settings/ASUS/M. Philadelphia: Lippincott Williams & Wilkins.

More distinct symptoms of a mood disturbance (such as depressed mood and sleep disturbance) should indicate a true coincident mood disturbance. as in mania or psychotic depression. these patients require the combination of an antipsychotic medication and a mood stabilizer. Schizophrenia is differentiated from schizoaffective disorder by the absence of a prominent mood disorder in the course of the illness. Typically. physical. SCHIZOPHRENIFORM DISORDER file:///C|/Documents%20and%20Settings/ASUS/.htm (10 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . MANAGEMENT Patients are treated with medications that target the psychosis and the mood disorder. and laboratory examination.Ovid: Blueprints Psychiatry history. Patients with schizoaffective disorder are more likely than those with schizophrenia but less likely than mood-disordered patients to have a remission after treatment. Medical conditions producing secondary behavioral symptoms should be ruled out. and increased rates of suicide. Complications of schizoaffective disorder include those related to antipsychotic and mood stabilizer medications. Psychosocial treatments are similar for schizoaffective disorder and schizophrenia. Mood stabilizers are described in Chapter 13. secondary consequences of poor healthcare and impaired ability to care for oneself.. Prognosis is better than for schizophrenia and worse than for bipolar disorder or major depression.. Differential Diagnosis Mood disorders with psychotic features. It is important to distinguish the prominent negative symptoms of the patient with schizophrenia from the lack of energy or anhedonia in the depressed patient with schizoaffective disorder.Chapter%201%20-%20Psychotic%20Disorders. are different from schizoaffective disorder in that patients with schizoaffective disorder have persistence (for at least 2 weeks) of the psychotic symptoms after the mood symptoms have resolved. preferably including brain magnetic resonance imaging. An antidepressant or electroconvulsive therapy may be needed for an acute depressive episode.

Outcome studies of this disorder indicate that most patients may go on to develop full-blown schizophrenia. and residual phases. CLINICAL MANIFESTATIONS History and Mental Status Examination Schizophreniform disorder is essentially short-course schizophrenia without the requirement of social withdrawal. including delusions.htm (11 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . ETIOLOGY At this time. but the duration of illness including prodromal.Ovid: Blueprints Psychiatry Essentially. active. Patients with this disorder have what appears to be a “full-blown” episode of schizophrenia. The diagnosis of schizophreniform disorder may help to avoid premature diagnosis of patients with schizophrenia before some other disorder. RISK FACTORS Because most patients with schizophreniform disorder are eventually diagnosed with schizophrenia. hallucinations. At least one study found similarities in brain structure abnormalities between patients with schizophrenia and those with schizophreniform disorder. manifests itself. or negative symptoms.Chapter%201%20-%20Psychotic%20Disorders. EPIDEMIOLOGY The validity of this diagnosis is under question. disorganized speech. schizophreniform disorder is schizophrenia that fails to last for 6 months and does not involve social withdrawal. is from 1 to 6 months.. such as bipolar disorder. the etiology is unknown.. whereas others appear to develop a mood disorder. risk factors are likely similar for the two groups. The diagnosis changes to schizophrenia once the symptoms have extended file:///C|/Documents%20and%20Settings/ASUS/.

6 Differential Diagnosis Care must be taken to distinguish schizophreniform disorder from a manic or depressive episode with psychotic features. it affects women more often than men. for example.. Generally. the recently immigrated person develops persecutory delusions. following migration. treatment is similar to that for the acute treatment of psychosis in schizophrenia. In migration psychosis.. Other causes of an acute psychosis must be ruled out (substance-induced or due to a general medical condition). Many patients with delusional disorder have a paranoid character pre-morbidly. MANAGEMENT The disorder is by definition self-limited. its course is long-term. When symptoms cause severe impairment. P. psychosocial stressors appear to be etiologic. EPIDEMIOLOGY This disorder is rare. Paranoid personality disorder has been found in families of patients file:///C|/Documents%20and%20Settings/ASUS/. with a prevalence of <0. Often. even if only residual symptoms are left.Chapter%201%20-%20Psychotic%20Disorders. It is rare.htm (12 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . ETIOLOGY The etiology is unknown. DELUSIONAL DISORDER Delusional disorder is characterized by nonbizarre delusions without other psychotic symptoms.Ovid: Blueprints Psychiatry past 6 months. onset is in middle to late life. and treatment is supportive.05%. Its course is generally long-term with remission uncommon.

. or being deceived by one's spouse or significant other). Mixed Unspecified A person is so diagnosed when no single delusional theme predominates. the patient's social adjustment may be normal. loved at a distance.Ovid: Blueprints Psychiatry with delusional disorder. A person becomes falsely convinced that he or she has special abilities or is in other ways much more important than reality indicates. Other than the delusion. poisoned. A person is so diagnosed when a single delusional theme cannot be determined or when the predominant delusional theme does not match subtype criteria.Chapter%201%20-%20Psychotic%20Disorders. Jealous Persecutory A person becomes falsely convinced that his or her lover is unfaithful. having a disease. Any mood disorder must be brief relative to the duration of the illness. The delusions must be present for at least 1 month. Somatic A person becomes falsely convinced that he or she has a bodily function disorder. body odor..htm (13 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . infected. CLINICAL MANIFESTATIONS History and Mental Status Examination This disorder is characterized by well-systematized nonbizarre delusions about events that could happen in real life (such as being followed. or parasite infection. The patient must not meet criteria for schizophrenia. for example. organ dysfunction. The DSM-IV recognizes seven subtypes of delusional disorder (Table 1-5). ▪ TABLE 1-5 Delusional Disorder Subtypes Erotomanic Grandiose A person becomes falsely convinced that another person is in love with him or her. A person becomes falsely convinced that others are out to harm him or her and that he or she is being conspired against in general. file:///C|/Documents%20and%20Settings/ASUS/.

. but it is also seen without any apparent antecedent.htm (14 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . the disorder seems to be associated with borderline personality disorder and schizotypal personality disorder. It can be temporally related to some stressor or occur postpartum. BRIEF PSYCHOTIC DISORDER In brief psychotic disorder. with an alliance. Thereafter. CLINICAL MANIFESTATIONS file:///C|/Documents%20and%20Settings/ASUS/. delusional disorder must be distinguished from major depression with psychotic features.Chapter%201%20-%20Psychotic%20Disorders.Ovid: Blueprints Psychiatry DIFFERENTIAL DIAGNOSIS It is important to rule out other psychiatric or medical illnesses that could have caused the delusions. Without such an alliance. ETIOLOGY Although the etiology is unknown. the patient may relinquish the delusions. and paranoid personality. most patients fall out of treatment..7 taking care neither to support nor to refute the delusion but to maintain an alliance with the patient. over time. the patient experiences a full psychotic episode that is short-lived. P. MANAGEMENT Trials of antipsychotics are appropriate but are often ineffective. EPIDEMIOLOGY There are insufficient data available to determine prevalence and gender ratio. The primary treatment is psychotherapy. schizophrenia. mania.

although the condition is by definition self-limited. hallucinations.htm (15 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . or grossly disorganized behavior.. KEY POINTS ● Schizophrenia is characterized by psychosis and social/occupational dysfunction that file:///C|/Documents%20and%20Settings/ASUS/. Patients can exhibit any combination of delusions. followed by eventual return to premorbid functioning. There are three recognized subtypes: with marked stressors (formerly known as brief reactive psychosis). and postpartum. disorganized speech. Patients with the postpartum subtype typically develop symptoms within 1 to 2 weeks after delivery that resolve within 2 to 3 months. the patient develops psychotic symptoms that last for at least 1 day but no more than 1 month. and no specific treatment is required..Chapter%201%20-%20Psychotic%20Disorders. which may last 2 to 3 months). The containing environment of the hospital milieu may be sufficient to help the patient recover. DIFFERENTIAL DIAGNOSIS It is important to rule out schizophrenia. without marked stressors. MANAGEMENT Hospitalization may be necessary to protect the patient. A mood disorder such as mania or depression with psychotic features must be ruled out. Treatment with antipsychotics is common.Ovid: Blueprints Psychiatry History and Mental Status Examination In brief psychotic disorder. especially if the disorder worsens or persists for more than a month (except for postpartum psychosis.

htm (16 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ . there are mood disturbances with psychotic episodes and there are periods of psychosis without a mood disturbance.Chapter%201%20-%20Psychotic%20Disorders. ● Schizoaffective disorder is treated with antipsychotics and mood stabilizers. ● Schizophreniform disorder resembles schizophrenia but resolves completely in less than 6 months (schizophrenia or bipolar disorder most often result). ● Schizophrenia has a 10% suicide rate (approximately one-third attempt suicide). ● The prognosis for schizoaffective disorder is better than for schizophrenia but worse than for a mood disorder.. ● Brief psychotic disorder is characterized by typical psychotic symptoms lasting from 1 to 30 days. ● file:///C|/Documents%20and%20Settings/ASUS/. ● Schizophrenia is treated with antipsychotics and psychosocial support. ● Delusional disorder is characterized by nonbizarre delusions and is long-term and unremitting.. ● In schizoaffective disorder.Ovid: Blueprints Psychiatry lasts for at least 6 months.

file:///C|/Documents%20and%20Settings/ASUS/.htm (17 of 17) [30/01/2009 06:21:10 ‫]ﻡ‬ ...Ovid: Blueprints Psychiatry Brief psychotic disorder can be preceded by a stressor or can be postpartum.Chapter%201%20-%20Psychotic%20Disorders.

Specific affected regions include the hippocampal formation. dysthymic disorder). 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 2 . and cyclothymic disorder). a genetic polymorphism producing reduced expression of the serotonin reuptake transporter has been associated with the risk for developing major depression when exposed to stressful life events. the cingulate gyrus (anterior portions). It is now clear that. Genetic factors are also emerging as increasingly important in influencing the risk for mood disorders. bipolar mood disorders (bipolar I disorder.iatry/Chapter%202%20-%20Mood%20Disorders. bipolar II disorder. There is emerging evidence that brain volume may be reduced in mood disorders.Ovid: Blueprints Psychiatry Authors: Murphy. in addition to altered function in the hypothalamic-pituitary adrenal axis and in multiple neurotransmitter systems. Mood is a persistent emotional state (as differentiated from affect. There are three major categories of mood disorders according to the Diagnostic and Statistical Manual of Mental Disorders. 4th edition (DSM-IV): unipolar mood disorders (major depressive disorder.Mood Disorders Chapter 2 Mood Disorders Mood disorders are among the most common diagnoses in psychiatry. Cowan. and mood disorders having a known etiology (substance-induced mood disorder and mood disorder caused by a general medical condition) (Table 2-1). giving rise to the concept of mixed mood states. that mood disorders are also associated with structural and functional brain alterations. which is the external display of feelings).. White matter changes in the form of increased hyperintensities on magnetic resonance imaging also occur.. Title: Blueprints Psychiatry. they can occur simultaneously in a single individual within a brief period.. Figure 2-1 depicts the major brain regions implicated in mood disorders.htm (1 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ . and the prefrontal cortex (especially dorsolateral prefrontal cortex). NEURAL BASIS The neural basis of mood disorders is slowly emerging. the amygdala. As an example. Although mania and depression are often viewed as opposite ends of the mood spectrum. Ronald L. most commonly in bipolar disorder type I. Michael J. UNIPOLAR DISORDERS file:///C|/Documents%20and%20Settings/ASUS/M. The best available evidence suggests that mood disorders lie on a continuum with normal mood.

A major depressive episode can occur at any time from early childhood to old age. The cognitive-behavioral model views cognitive distortions as the primary events that foster a negative misperception of the world. which in turn. and socioeconomic variables do not seem to be a factor.. In fact.htm (2 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ .iatry/Chapter%202%20-%20Mood%20Disorders. Race distributions appear equal.5% of children and 8% of adolescents suffer from depression.. although more recent theories focus on the critical importance of the object relationship in maintaining psychic equilibrium and self-regard. and energy levels. depression affects 1% to 3% of elderly persons. consisting of alterations in sleep.Ovid: Blueprints Psychiatry Unipolar disorders are major depressive disorder and dysthymic disorder. It is characterized by emotional changes. available evidence suggests that childhood loss of a parent or loss of a spouse is associated with depression. The female:male ratio is 2:1. ▪ TABLE 2-1 Classification of Mood Disorder Unipolar Major depressive disorder Dysthymic disorder Bipolar Bipolar I disorder Bipolar II disorder Cyclothymic disorder Etiologic Substance-induced mood disorder Mood disorder due to general medical condition ETIOLOGY Psychological theories of depression generally view interpersonal losses (actual or perceived) as risk factors for developing depression. EPIDEMIOLOGY The lifetime prevalence (will occur at some point in a person's life) rate for major depressive disorder is 5% to 20%. generate file:///C|/Documents%20and%20Settings/ASUS/M. Classic psychoanalytic theories center on ambivalence toward the lost object (person). appetite.9 decreases after the age of 65. primarily depressed mood. and by so-called vegetative changes. The incidence (rate of new cases) is greatest between the ages of 20 and 40 and P. MAJOR DEPRESSIVE DISORDER Major depressive disorder is diagnosed after a single episode of major depression (Table 2-2). Approximately 2.

▪ TABLE 2-2 Diagnostic Criteria for Major Depressive Episode Mood: depressed mood most of the day.. cannot be substance-induced. Diagnostic and Statistical Manual of Mental Disorders. suicide attempt General criteria for a major depressive episode require five or more of the above symptoms to be present for at least 2 weeks. suicidal plan. Reproduced with permission from the American Psychiatric Association. 2000. and cannot be caused by bereavement. These symptoms must be a change from prior functioning and cannot be a result of a medical condition. one symptom must be depressed mood or loss of interest or pleasure.htm (3 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ . The learned helplessness model (based on animal studies) suggests that depression arises when individuals come to believe they have no control over the stresses and pains that beset them. suicidal ideation. The symptoms must also cause distress or impairment. 4th ed (text revision). DC: American Psychiatric Association.iatry/Chapter%202%20-%20Mood%20Disorders.. Washington. nearly every day Sleep: insomnia or hypersomnia Interest: marked decrease in interest and pleasure in most activities Guilt: feelings of worthlessness or inappropriate guilt Energy: fatigue or low energy nearly every day Concentration: decreased concentration or increased indecisiveness Appetite: increased or decreased appetite or weight gain or loss Psychomotor: psychomotor agitation or retardation Suicidality: recurrent thoughts of death.Ovid: Blueprints Psychiatry negative emotions. file:///C|/Documents%20and%20Settings/ASUS/M.

(Courtesy of Anatomical Chart Company. and cingulate gyrus.. amygdala. familial.) Biologic.Ovid: Blueprints Psychiatry Figure 2-1 • Brain regions showing structural and functional alteration in depression include the hippocampus.htm (4 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ . stages 3 and 4) is decreased in depression and that rapid eye movement (REM) sleep alterations include increased time spent in REM and earlier onset of REM in the sleep cycle (decreased latency to REM). and genetic data support the idea of a biologic diathesis in the genesis of depression. CLINICAL MANIFESTATIONS History and Mental Status Examination file:///C|/Documents%20and%20Settings/ASUS/M. P. Objective evidence from sleep studies reveals that deep sleep (delta sleep. Neuroendocrine abnormalities in the hypothalamic-pituitary-adrenal axis are often present in depression and suggest a neuroendocrine link. Sleep disturbances are nearly universal complaints in depressed persons.. Other affected regions of frontal lobe include medial superior frontal gyrus and not shown (dorsolateral prefrontal cortex). Unipolar depression in a parent leads to an increased incidence of both unipolar and bipolar mood disorders in their offspring.10 Genetic studies show that depression is found to be concordant more often in monozygotic twins than in dizygotic twins. Neurotransmitter evidence points to abnormalities in amine neurotransmitters as mediators of depressive states: the evidence is strongest for deficiencies in norepinephrine and serotonin.iatry/Chapter%202%20-%20Mood%20Disorders.

The usual duration of an untreated episode (Fig. negative symptoms of schizophrenia can mimic depression. problems with authority.Ovid: Blueprints Psychiatry A major depressive disorder is diagnosed if a patient experiences at least one episode of major depression and does not meet criteria for bipolar disorder or etiologic mood disorder. energy. Irritability may be the primary mood complaint in some cases. Psychotic depression must be differentiated from schizophrenia. Vegetative symptoms include alterations in sleep. and anger outbursts. present with the usual adult symptoms and with higher rates of co-occurring anxiety.htm (5 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ . and despair. frequent headaches or stomachaches.iatry/Chapter%202%20-%20Mood%20Disorders. hopelessness. In addition to the symptoms seen in adults. Major depression is characterized by emotional and vegetative changes. loss. 15% die by suicide at some point in their lifetime. and libido. Differential Diagnosis Mood disorders secondary to (induced by) medical illnesses or substance abuse are the primary differential diagnoses. Elderly persons. Of patients diagnosed with major depression. Major depression is frequently recurrent. White men over age 65 have a suicide rate that is five times that of the general population. guilt. file:///C|/Documents%20and%20Settings/ASUS/M. or medical illness.. appetite. children present with school avoidance. often beset by grief. 2-2A) is 6 to 12 months. Persons with major depression may eventually meet criteria for bipolar disorder.. Emotional changes most commonly include depressed mood with feelings of sadness.

and atypical antidepressants. Elderly persons with depression do best when low dosages of antidepressants are initiated and raised slowly in conjunction with psychotherapy. available classes of antidepressants include tricyclic antidepressants. MANAGEMENT Depression is responsive to psychotherapy and pharmacotherapy. (B) Dysthymic disorder. Anxiolytics may be used as adjuncts to antidepressants in depression with high levels of anxiety.htm (6 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry Figure 2-2 • Unipolar mood disorders. a novel bioelectrical treatment involving the electrical stimulation of the vagus nerve via a surgically implanted device has shown some promise as a potential treatment for major depression..11 monoamine oxidase inhibitors..g. selective serotonin reuptake inhibitors. thyroid hormone. supportive. or treatment-refractory depressions or when medications are contraindicated (e. and psychostimulants may be used as augmentative treatments. P. severe. lithium. At present.. cognitive-behavioral. Electroconvulsive therapy (ECT) is used in psychotic. Among the psychotherapies. Antipsychotic medications are an essential adjunct to antidepressants in psychotic depressions and may be helpful even in nonpsychotic depression. antidepressant medications combined with psychotherapy are superior to medications or psychotherapy alone. and brief interpersonal therapies have the most data to support their efficacy. (A) Major depressive disorder. although current use is still limited by cost and availability.iatry/Chapter%202%20-%20Mood%20Disorders. Children and adolescents with depression benefit from some antidepressants and from psychotherapy as well. Phototherapy can be used for seasonal mood disorders. There are many classes of antidepressants available that are effective and are usually chosen according to side-effect profiles. in elderly or debilitated individuals). Milder cases may be treated with brief psychotherapy interventions alone. There is a long tradition of psychodynamic psychotherapy in treating depression. In addition. although moresedating antidepressants may suffice. They may be at higher risk of suicide during active pharmacologic treatment. Vagal nerve stimulation. and sufferers should be carefully followed by a mental health specialist. file:///C|/Documents%20and%20Settings/ASUS/M. although it has not been well studied empirically. For more severe cases.

Dysthymia can be chronic and difficult to treat. BIPOLAR I DISORDER Bipolar I disorder is the most serious of the bipolar disorders and is diagnosed after at least one episode of mania (Table 2-3). and cyclothymia. Associated symptoms and complaints may include change in appetite and sleep.Ovid: Blueprints Psychiatry DYSTHYMIC DISORDER Dysthymic disorder is a mild. fatigue.. file:///C|/Documents%20and%20Settings/ASUS/M. 2-2B). ETIOLOGY Because dysthymia is often conceptualized as a milder. BIPOLAR DISORDERS The bipolar disorders are bipolar I disorder.htm (7 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ . similar etiologies are generally attributed to dysthymia. giving rise to the term double depression. chronic form of major depression.. CLINICAL MANIFESTATIONS History and Mental Status Examination Dysthymic disorder is a chronic and less severe form of major depression. Differential Diagnosis Major depression and etiologic mood disorders are the primary differential diagnostic considerations. EPIDEMIOLOGY The lifetime prevalence is 6%.iatry/Chapter%202%20-%20Mood%20Disorders. The diagnosis of dysthymia requires that an individual experience a minimum of 2 years of chronically depressed mood most of the time (Fig. decreased concentration. At times. Patients with bipolar I disorder typically also experience major depressive episodes in the course of their lives. and hopelessness. and the course of treatment may be more protracted. chronic form of major depression. major depressive episodes may co-occur. MANAGEMENT Treatment is similar to major depression except that psychotherapy may play a larger role. bipolar II disorder.

P. A single manic episode is sufficient to meet diagnostic requirements. bipolar II. expansive.Ovid: Blueprints Psychiatry EPIDEMIOLOGY The lifetime prevalence is 0. DC: American Psychiatric Association. 2000. Reproduced with permission from the American Psychiatric Association. Washington. most patients. CLINICAL MANIFESTATIONS History and Mental Status Examination Bipolar I disorder is defined by the occurrence of mania (or a mixed episode).6% and the male:female ratio is equal.4% to 1. 4th ed (text revision). or irritable mood lasting 1 week or severe enough to require hospitalization. ETIOLOGY Genetic and familial studies reveal that bipolar I disorder is associated with increased bipolar I. spending.. however. These symptoms must be a change from prior functioning and cannot be because of a medical condition and cannot be substance-induced. There are no racial variations in incidence. X linkage has been shown in some studies but remains controversial. and there is evidence that sleep/wake cycle perturbations may predispose a person to mania.12 ▪ TABLE 2-3 Diagnostic Criteria for Manic Episode Three to four of the following criteria are required during the elevated mood period: Self-esteem: highly inflated. Diagnostic and Statistical Manual of Mental Disorders. travel) General criteria for a manic episode require a clear period of persistently elevated. Mania can be precipitated by psychosocial stressors.. The symptoms must also cause distress or impairment. The criteria for a manic episode are outlined in Table 2-3. file:///C|/Documents%20and%20Settings/ASUS/M. rested after only a few hours Speech: pressured Thoughts: racing thoughts and flight of ideas Attention: easy distractibility Activity: increased goal-directed activity Hedonism: high excess involvement in pleasurable activities (sex.iatry/Chapter%202%20-%20Mood%20Disorders. and major depressive disorders in first-degree relatives. have recurrent episodes of mania typically intermixed with depressive episodes. grandiosity Sleep: decreased need for sleep.htm (8 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ .

htm (9 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ . Lifetime suicide rates range from 10% to 15%. gabapentin. psychostimulants. The transition between mania and depression occurs without an intervening period of euthymia in about two of three patients (Fig. slightly older children might try to teach their grammar school class in the presence of their teacher. Schizoaffective disorder. appear to act as mood stabilizers and are increasingly being used for maintenance of bipolar disorder. Pharmacologic interventions for acute mania include antipsychotics in conjunction with benzodiazepines (for rapid tranquilization) and initiation of mood stabilizer medication. MANAGEMENT Persons experiencing a manic episode often have poor insight and resist treatment. including antidepressant medications. Antipsychotics are frequently used in mania with and without psychotic features. file:///C|/Documents%20and%20Settings/ASUS/M. and long-acting benzodiazepines are used if first-line treatments fail. although studies on the safety and effectiveness of such combinations are lacking. or depressed episodes is used in patients with medication P. 2-3A). Most children with bipolar disorder have more than one relative with the condition.iatry/Chapter%202%20-%20Mood%20Disorders. A first episode of bipolar disorder in elderly individuals is rare. but valproic acid is quite effective and is more effective for the rapid-cycling variant of mania.Ovid: Blueprints Psychiatry The first episode of mania usually occurs in the early 20s. ECT. Mood disorder caused by a general medical condition is the other major differential consideration. and depression with agitation are also considerations.g.. borderline personality disorder.. Manic episodes are typically briefer than depressive episodes. Combination medication therapy is more common than monotherapy. Some atypical antipsychotics. olanzapine. the patient is diagnosed with substance-induced mood disorder. Children can present with bipolar disorder that resembles the adult-type but differs according to age and developmental level. Differential Diagnosis Mania may be induced by antidepressant treatment. and aripiprazole. Medical or neurological causes of new bipolar disorder in an older person should be thoroughly investigated. quetiapine. not bipolar disorder. particularly clozapine.13 intolerance and when a more immediate response is medically or psychiatrically needed (e. mixed episodes. Co-occurring psychiatric problems and psychosocial difficulties are the norm. When this occurs. Children and adolescents are treated with medications similar to those of adults. often in combination. Lithium is the most commonly used mood stabilizer. lamotrigine. and phototherapy. and adolescents might present with severe anger outbursts and agitation. ECT for mania. to treat a severely suicidal patient). Very young children might present with uncontrollable giggling. Carbamazepine..

to help patients come to terms with their illness. infidelity. (A) Bipolar I disorder.Ovid: Blueprints Psychiatry but with even fewer studies backing up various treatment strategies. and hypomania (a milder form of elevated mood than mania) is the essential diagnostic finding. Mood stabilizer maintenance therapy is essential in preventing the recurrence of mania and appears to decrease the recurrence of depression. hostility. squandering money).. file:///C|/Documents%20and%20Settings/ASUS/. and to help repair some of the interpersonal damage done while ill (e. (C) Cyclothymic disorder. Figure 2-3 • Bipolar mood disorders..htm (10 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ .g.atry/Chapter%202%20-%20Mood%20Disorders.. BIPOLAR II DISORDER Bipolar II disorder is similar to bipolar I disorder except that mania is absent in bipolar II disorder. Care must be taken when prescribing antidepressants for depression or dysthymia because of their role in prompting more severe or more frequent manic episodes. Psychotherapy is used to encourage medication compliance. (B) Bipolar II disorder.

although hypomanic episodes typically do not P. Care must be taken in prescribing antidepressants for depression or dysthymia because of their role in prompting more severe or frequent hypomanic episodes.atry/Chapter%202%20-%20Mood%20Disorders. CYCLOTHYMIC DISORDER Cyclothymic disorder is a recurrent. mild form of bipolar disorder in which mood typically oscillates between hypomania and dysthymia. cause less impairment. chronic..5%.htm (11 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ .14 require as aggressive a treatment regimen as does mania.4% to 1%.Ovid: Blueprints Psychiatry EPIDEMIOLOGY The lifetime prevalence of bipolar II disorder is about 0. Differential Diagnosis The differential diagnosis for bipolar II disorder is the same as for bipolar I disorder. EPIDEMIOLOGY The lifetime prevalence of cyclothymic disorder is 0. Bipolar II disorder may be more common in women. Hypomania is determined by the same symptom complex as mania. although women more often seek treatment. file:///C|/Documents%20and%20Settings/ASUS/. the course of untreated bipolar II is presented in Figure 2-3B. It is not diagnosed if a person has experienced either a manic episode or a major depressive episode. ETIOLOGY Current evidence implicates the same factors as for bipolar I. Bipolar II disorder is cyclic.. but the symptoms are less severe. CLINICAL MANIFESTATIONS History and Mental Status Examination Bipolar II disorder is characterized by the occurrence of hypomania and episodes of major depression in an individual who has never met criteria for mania or a mixed state. Suicide occurs in 10% to 15% of patients. The rate appears equal in men and women. and usually do not require hospitalization. MANAGEMENT The treatment is the same as for bipolar I disorder.

and mood disorder as a result of a general medical condition. unipolar. Persons with cyclothymia. A single episode of hypomania is sufficient to diagnose cyclothymic disorder. or phototherapy are proximate events and the likely cause of the mood disturbance. The course of untreated cyclothymic disorder is depicted in Figure 2-3C. may never seek medical attention for their mood symptoms. most individuals also have dysthymic periods. Personality disorders (especially borderline) with labile mood may be confused with cyclothymic disorder. Endocrine disorders.. mood stabilizers. ECT. file:///C|/Documents%20and%20Settings/ASUS/. Cyclothymic disorder is never diagnosed when there is a history of mania or major depressive episode or mixed episode. CLINICAL MANIFESTATIONS History and Mental Status Examination Cyclothymic disorder is a milder form of bipolar disorder consisting of recurrent mood disturbances between hypomania and dysthymic mood..Ovid: Blueprints Psychiatry ETIOLOGY Familial and genetic studies reveal an association with other mood disorders. they are modifiers of unipolar and bipolar mood disorders. and antidepressants are used. Differential Diagnosis The principal differential is among other unipolar and bipolar mood disorders. All the aforementioned types of mood disorder (e.htm (12 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ . bipolar) may occur. however.g. however.atry/Chapter%202%20-%20Mood%20Disorders. are common etiologies. MOOD DISORDERS WITH KNOWN ETIOLOGY SUBSTANCE-INDUCED MOOD DISORDER Substance-induced mood disorder is diagnosed when medications. other psychoactive substances. Postpartum mood disorders are excluded from the criteria. MANAGEMENT Psychotherapy.. such as thyroid and adrenal dysfunction. MOOD DISORDER RESULTING FROM A GENERAL MEDICAL CONDITION This category is for mood disturbances apparently caused by a medical illness. substance-induced mood disorder.

The reverse is sometimes true. The suicide rate may be higher than in nonrapid cyclers.. These have prognostic and treatment implications and may prove to have etiologic implications. including motoric immobility or excessive purposeless motor activity. If the depression P. four mood disturbances per year must be present. To meet criteria for rapid cycling. stereotyped movement. ● Rapid Cycling: Patients with bipolar disorder may have frequent (rapid) cycles. the manic and hypomanic episodes may show a seasonal association.htm (13 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ . anergia.atry/Chapter%202%20-%20Mood%20Disorders. maintenance of a rigid posture. remorse. increased appetite or weight gain. ● Postpartum: Postpartum depression occurs within 4 weeks of childbirth. The most common pattern is a worsening of depression during the fall and winter with improvement in the spring. loss of pleasure. echolalia (repetition of a word or phrase just spoken by another person). and echopraxia (repetition of movements made by another person). ● Melancholic: Melancholic depression is a severe form of depression associated with guilt. The presence of one episode of postpartum mood disorder is strongly predictive of a recurrence. file:///C|/Documents%20and%20Settings/ASUS/. and leaden paralysis. and extreme vegetative symptoms. ● Catatonic: The catatonic specifier is applied to mood disorders when there are pronounced movement abnormalities.. mood reactivity.Ovid: Blueprints Psychiatry Subtypes and Modifiers Various diagnostic specifiers can be applied to specific subtypes of mood disorders.15 is a component of a bipolar disorder. ● Seasonal: Seasonal mood disorders show a consistent seasonal pattern of variation. ● Atypical: Atypical depressions show a pattern of hypersomnia. long-standing rejection sensitivity. mutism.

● Bipolar I disorder is a biphasic cyclic mood disorder with a 10% to 15% suicide rate. ● Dysthymia is a chronic unipolar mood disorder (lasting at least 2 years). ● Dysthymia is often refractory to treatment. ● Bipolar I disorder requires maintenance treatment with mood stabilizers. the suicide rate is 10% to 15%. ● Combined psychotherapy and pharmacotherapy is the best treatment for major depression. ● Bipolar II disorder is a biphasic recurrent mood disorder with hypomania.htm (14 of 14) [30/01/2009 06:21:17 ‫]ﻡ‬ .. recurrent biphasic mood disorder without frank mania or depression. ● Cyclothymic disorder is a chronic.atry/Chapter%202%20-%20Mood%20Disorders. file:///C|/Documents%20and%20Settings/ASUS/. combination therapy is common..Ovid: Blueprints Psychiatry KEY POINTS ● Major depression is a recurrent unipolar mood disorder with a 15% suicide rate.

7.Ovid: Blueprints Psychiatry Authors: Murphy. glutamate. Anxiety disorders are a heterogeneous group of disorders in which the feeling of anxiety is the major element. Anxiety disorders listed in the Diagnostic and Statistical Manual of Mental Disorders. serotonin (from the raphe nuclei). Anxiety disorders have strong associations with fear. Ronald L. Cowan. NEURAL BASIS The anxiety disorders do not have a universally shared neurobiological basis. and has a variety of psychologic and physical manifestations. Title: Blueprints Psychiatry. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 3 .. Michael J. but emerging evidence links anxiety to alterations in norepinephrine (from the locus ceruleus). transient or chronic. 4th edition (DSM-IV) are shown in Table 3-1. and peptide neurotransmitters (neuropeptide Y and galanin). Obsessive-compulsive disorder (OCD) has been linked to altered caudate and cingulate gyrus function.3% of all Americans meet the Diagnostic and Statistical Manual of Mental Disorders.ry/Chapter%203%20-%20Anxiety%20Disorders. the DSM version used at the time) criteria at a given point in time (so-called point prevalence).. They are the most prevalent group of psychiatric disorders. 3rd edition (DSM-III.Anxiety Disorders Chapter 3 Anxiety Disorders The term anxiety refers to many states in which the sufferer experiences a sense of impending threat or doom that is not well defined or realistically based.htm (1 of 21) [30/01/2009 06:21:24 ‫]ﻡ‬ . γ-aminobutyric acid (GABA). and the amygdala is thought to play an important role in this regard.. Regions of prefrontal cortex and file:///C|/Documents%20and%20Settings/ASUS/M. Anxiety can be adaptive or pathologic. according to the Epidemiological Catchment Area study.

. with a lifetime prevalence of between 2% and 6%. with a lifetime prevalence of 2% to 3%. ETIOLOGY The etiology of panic disorder is unknown. EPIDEMIOLOGY Panic disorder occurs more frequently in women. Agoraphobia also occurs more frequently in women. Most patients with agoraphobia seen clinically also have panic disorder.htm (2 of 21) [30/01/2009 06:21:24 ‫]ﻡ‬ . and elevated central nervous system catecholamine P. sometimes disabling. panic disorder and agoraphobia are common.17 file:///C|/Documents%20and%20Settings/ASUS/M. such as in posttraumatic stress disorder (PTSD). Only one-third of patients with agoraphobia also have panic disorder. PANIC DISORDER AND AGORAPHOBIA Panic disorder is characterized by recurrent unexpected panic attacks that can occur with or without agoraphobia.ry/Chapter%203%20-%20Anxiety%20Disorders. Whether occurring as distinct disorders or together.. Table 3-2 outlines diagnostic criteria for a panic attack. an abnormality of the locus ceruleus (a region in the brain that regulates level of arousal). This apparent contradiction is because patients with agoraphobia alone are unlikely to seek treatment. Agoraphobia is a disabling condition in which patients fear places from which escape might be difficult. Hippocampal dysfunction may play a role in conditions associated with recall of fearful or traumatic events. however.Ovid: Blueprints Psychiatry hippocampus are also important. with most cases beginning before age 30. abnormalities in lactate metabolism. The typical onset is in the 20s. conditions. There are several popular biologic theories involving carbon dioxide hypersensitivity (potentially involving medullary cholinergic function).

ry/Chapter%203%20-%20Anxiety%20Disorders.. The GABA receptor has also been implicated as etiologic because patients respond well to benzodiazepines and because panic is induced in patients with anxiety disorders using GABA antagonists. experienced during exercise or any sympathetic nervous system response. 4th ed.htm (3 of 21) [30/01/2009 06:21:24 ‫]ﻡ‬ . Theorists posit that panic attacks are a conditioned response to a fearful situation. a person has an automobile accident and experiences severe anxiety. Diagnostic and Statistical Manual of Mental Disorders. For example. palpitations alone. CLINICAL MANIFESTATIONS file:///C|/Documents%20and%20Settings/ASUS/M. including palpitations. DC: American Psychiatric Association. ▪ TABLE 3-1 Anxiety Disorders Panic disorder with agoraphobia Panic disorder without agoraphobia Agoraphobia Social phobia Obsessive-compulsive disorder Generalized anxiety disorder Acute stress disorder Posttraumatic stress disorder Substance-induced anxiety disorder Anxiety disorder caused by a general medical condition Anxiety disorder not otherwise specified Adapted from the American Psychiatric Association..Ovid: Blueprints Psychiatry levels. Thereafter. may induce the conditioned response of a panic attack. 2000. Washington.

allowing them to enter some public places with less anxiety. and last 5 to 30 minutes. restriction of activities). It is characterized by an intense fear of places or situations in which escape might be difficult (or embarrassing).. worry about the implications of the attack (losing control.g. Patients with agoraphobia and panic disorder typically fear having a panic attack in a public place and being embarrassed or unable to escape. many are comforted by the presence of a companion. To warrant the diagnosis.Ovid: Blueprints Psychiatry History and Mental Status Examination Panic disorder is characterized by recurrent. Those with agoraphobia alone (two-thirds of those with agoraphobia) simply avoid public arenas but do not have panic attacks. Although some patients with agoraphobia are so disabled that they are homebound. ▪ TABLE 3-2 Diagnostic Criteria for Panic Attacks A discrete period of intense fear or discomfort. or a significant change of behavior related to the attacks (e. The patient must experience four of the 13 typical symptoms of panic outlined in Table 3-2.. one of the following must occur for at least 1 month: persistent concern about having additional attacks. Agoraphobia is a disabling complication of panic disorder but can also occur in patients with no history of panic disorder. unexpected panic attacks that can occur with or without agoraphobia (information to follow). in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes: • • • • Palpitations.htm (4 of 21) [30/01/2009 06:21:24 ‫]ﻡ‬ . Panic attacks typically come on suddenly. pounding heart. or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering file:///C|/Documents%20and%20Settings/ASUS/M. peak within minutes.ry/Chapter%203%20-%20Anxiety%20Disorders. “going crazy”)..

Ovid: Blueprints Psychiatry • • • • • • • • • Feeling of choking Chest pain or discomfort Nausea or abdominal distress Feeling dizzy. and coronary artery disease. cardiac conditions. The panic attacks also cannot be accounted for by another mental disorder. Diagnostic and Statistical Manual of Mental Disorders. need to be carefully excluded. Use of psychostimulants P. valvular abnormalities..htm (5 of 21) [30/01/2009 06:21:24 ‫]ﻡ‬ . lightheaded. DC: American Psychiatric Association. 4th ed. unsteady.ry/Chapter%203%20-%20Anxiety%20Disorders. such as social phobia or OCD. In particular.18 such as cocaine or crystal methamphetamine must also be ruled out. such as rhythm disturbances. Washington. 2000. Differential Diagnosis Panic attacks should be distinguished from the direct physiologic effects of a substance or a general medical condition (particularly cardiac conditions or partial complex epilepsy). or faint Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of dying Paresthesias Chills or hot flushes Adapted from the American Psychiatric Association.. Diagnostic Evaluation Panic disorder is diagnosed after taking a thorough history and performing necessary physical and laboratory examinations to rule out medical causes. file:///C|/Documents%20and%20Settings/ASUS/M.

in which the patient incrementally confronts a feared stimulus..Ovid: Blueprints Psychiatry MANAGEMENT The main treatments for panic disorder are pharmacotherapy and cognitive-behavioral therapy or their combination. Patients can then learn that the sensations are innocuous and self-limited. which diminishes the panicky response. (2) natural environment type. heights) Marked immediate anxiety upon exposure to feared stimulus Individual recognizes that the fear is excessive/unreasonable The feared stimulus is avoided or endured with much anxiety/distress The individual is significantly impaired by the anxiety/distress or avoidance file:///C|/Documents%20and%20Settings/ASUS/M. snakes. Exposure therapy. ▪ TABLE 3-3 Diagnostic Criteria for Specific Phobia Fear Anxiety Insight Avoidance Impairment Intense fear of particular objects or situations (e.ry/Chapter%203%20-%20Anxiety%20Disorders. Cognitive-behavioral therapy (CBT) involves the use of relaxation exercises and desensitization combined with education aimed at helping patients to understand that their panic attacks are a result of misinterpreting bodily sensations. heights). specific monoamine oxidase inhibitors (MAOIs). It is the most common psychiatric disorder. SPECIFIC PHOBIA Specific phobia is an anxiety disorder characterized by intense fear of particular objects or situations (e.g. (4) situational type.htm (6 of 21) [30/01/2009 06:21:24 ‫]ﻡ‬ . DSM-IV criteria for specific phobia are depicted in Table 3-3. Specific tricyclic antidepressants. and (5) other type..g. has been shown to be effective in treating agoraphobia. DSM-IV identifies four category-specific subtypes of specific phobia and one general category: (1) animal type. snakes. and highpotency benzodiazepines have been shown to be effective in controlled studies.. (3) blood-injection-injury type.. selective serotonin reuptake inhibitors (SSRIs).

htm (7 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . To meet the DSM-IV criteria for specific phobia. with most cases occurring before age 12. Behavioral theorists argue that phobias are learned by being paired with traumatic events. activity.19 file:///C|/Documents%20and%20Settings/ASUS/M.Ovid: Blueprints Psychiatry Duration Specific Duration of at least 6 months (in individuals younger than age 18) The symptoms are not better accounted for by another condition Adapted from the American Psychiatric Association. tend to run in families. 2000. Diagnostic and Statistical Manual of Mental Disorders. a patient must experience a marked. 4th ed. and the avoidance of or distress over the feared situation must impair everyday activities or relationships. CLINICAL MANIFESTATIONS History and Mental Status Examination A phobia is an irrational fear of a specific object. EPIDEMIOLOGY Specific phobias are more prevalent in women than men and occur with a lifetime prevalence of 25%. For those younger than age 18. persistent fear that is recognized by the patient to be excessive or unreasonable and is cued by the presence or anticipation of a specific object or situation. P.ry/Chapter%203%20-%20Anxiety%20Disorders. DC: American Psychiatric Association. ETIOLOGY Phobic disorders. In addition. Washington. symptoms must persist for at least 6 months. The typical onset is in childhood. exposure to the stimulus must almost invariably provoke the anxiety reaction.. place. including specific phobia.. or situation that is out of proportion to any actual danger.

.. SOCIAL PHOBIA Social phobia (also known as social anxiety disorder) is an anxiety disorder in which patients have an intense fear of being scrutinized in social or public situations (e. psoriasis). tend to run in families. The typical onset is in adolescence. speaking in class).g. EPIDEMIOLOGY Social phobias occur equally among men and women and affect 3% to 5% of the population. The disorder may be generalized or limited to specific situations.. Behavioral theorists argue that phobias are learned by being paired with traumatic events. but the social anxiety is not related to what others think of the psoriasis but might be a fear of voice cracking (e. Exposure therapy in the form of systematic desensitization or flooding is the treatment of choice. DSM-IV criteria are outlined in Table 3-4.htm (8 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . When they persist into adulthood.g.. including social phobia. in a singing performance. they often become chronic. If symptoms occur in most social situations. giving a speech. ETIOLOGY Phobic disorders. they rarely cause disability. with most cases occurring before age 25.ry/Chapter%203%20-%20Anxiety%20Disorders. Some theorists posit that hypersensitivity to rejection is a psychological file:///C|/Documents%20and%20Settings/ASUS/M..g. There is little role for medication. The context criteria refer to circumstances in which one might have a medical condition (e. the social phobia is specified as generalized social phobia. however. MANAGEMENT Specific childhood phobias tend to remit spontaneously with age. etc.Ovid: Blueprints Psychiatry Differential Diagnosis The principal differential diagnosis is another mental disorder (such as avoidance of school in separation anxiety disorder) presenting with anxiety or fearfulness.).

. Exposure to the feared social situation must almost invariably provoke an anxiety reaction. Social phobia can either be generalized (the patient fears nearly all situations) or limited to specific situations. the fear/anxiety is not related to the actual medical condition file:///C|/Documents%20and%20Settings/ASUS/M.htm (9 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . Avoidance of or distress over the feared situation must impair everyday activities or relationships.ry/Chapter%203%20-%20Anxiety%20Disorders.Ovid: Blueprints Psychiatry antecedent of social phobia. For those younger than age 18.. CLINICAL MANIFESTATIONS History and Mental Status Examination Social phobias are characterized by the fear of situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. ▪ TABLE 3-4 Diagnostic Criteria for Social Phobia (Social Anxiety Disorder) Fear Intense fear of a social or performance situation involving exposure to strangers or perceived scrutiny by others Anxiety Insight Avoidance Impairment Duration Specific Context Anxiety upon exposure to the feared situation Individual recognizes that the fear is excessive/unreasonable Avoidance of feared situation or endurance with much distress The anxiety/avoidance impairs functioning Duration of at least 6 months (in individuals younger than age 18) The symptoms are not better explained by another condition When an actual medical condition is present. symptoms must persist for at least 6 months.

and gabapentin have proved successful in treating social phobia. in panic disorder. Supportive individual and group psychotherapy is helpful to restore self-esteem and to encourage venturing into feared situations. The associated symptoms highlight the physical and mental components of GAD. The typical age of onset is in the early 20s. Diagnostic and Statistical Manual of Mental Disorders.htm (10 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . DC: American Psychiatric Association.y/Chapter%203%20-%20Anxiety%20Disorders. The context criteria mean that the focus of the anxiety is not about a symptom related to another Axis I condition (for example. excessive worry about having a panic attack would not be a symptom of GAD). 4th ed.Ovid: Blueprints Psychiatry Adapted from the American Psychiatric Association. CBT uses the exposure therapy techniques of flooding and P.. 2000. GENERALIZED ANXIETY DISORDER Generalized anxiety disorder (GAD) is characterized by intense pervasive worry over virtually every aspect of life associated with physical manifestations of anxiety. but many cases require medication. DSM-IV criteria for GAD are outlined in Table 3-5. SSRIs. alprazolam. Differential Diagnosis The principal differential diagnosis is another mental disorder (such as avoidance of school in separation anxiety disorder) presenting with anxiety or fearfulness. but the disorder may file:///C|/Documents%20and%20Settings/ASUS/. MAOIs. EPIDEMIOLOGY The lifetime prevalence of GAD is approximately 5%.20 systematic desensitization to reduce anxiety in feared situations. SSRIs appear to be the most effective pharmacotherapy. β-blockers. Washington. MANAGEMENT Mild cases of social phobia can be treated with CBT..

and GABA-ergic neurotransmitter systems have been studied in relation to GAD. on edge three of six symptoms 2.y/Chapter%203%20-%20Anxiety%20Disorders.. disturbed sleep Context Focus of anxiety and worry does not occur in the context of another psychiatric disorder file:///C|/Documents%20and%20Settings/ASUS/.. irritability 5.Ovid: Blueprints Psychiatry begin at any age. keyed up. restlessness. trouble concentrating/blank mind 4. noradrenergic. but the biologic etiology remains obscure. ▪ TABLE 3-5 Diagnostic Criteria for Generalized Anxiety Disorder Anxiety and worry Excessive worry and anxiety for most days over a 6-month period about multiple events or situation Uncontrollable Associated symptoms Worry that is difficult to control Anxiety and worry are associated with at least 1. Cognitive-behavioral theorists posit that GAD is caused by cognitive distortions in which patients misperceive situations as dangerous when they are not. muscle tension 6. ETIOLOGY Twin studies suggest that GAD has both inherited and environmental etiologies. easily fatigued 3. Serotonergic.htm (11 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ .

For example. Diagnostic and Statistical Manual of Mental Disorders. 2000. muscle tension.. marital relations. health. or compulsions. They must also have difficulty controlling the worry. or other psychiatric condition Adapted from the American Psychiatric Association.Ovid: Blueprints Psychiatry Impairment The anxiety and worry significantly impair function Specific Anxiety and worry are not caused by drugs. They do not have panic attacks. DC: American Psychiatric Association. Differential Diagnosis The focus of the anxiety and worry in GAD must not be symptomatic of another Axis I disorder. the anxiety and worry cannot be about having a panic attack (as in panic disorder) or being embarrassed in public (as in social phobia). 4th ed.. irritability. CLINICAL MANIFESTATIONS History and Mental Status Examination Patients with generalized anxiety disorder worry excessively about virtually every aspect of their lives (job performance. a general medical condition. difficulty concentrating or mind going blank. and social life). rather. phobias. obsessions. P. easily fatigued.21 file:///C|/Documents%20and%20Settings/ASUS/.htm (12 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . they experience pervasive anxiety and worry (apprehensive expectation) about a number of events or activities that occur most days for at least 6 months. Washington. and it must be associated with at least three of the following symptoms: restlessness.y/Chapter%203%20-%20Anxiety%20Disorders. and sleep disturbance.

y/Chapter%203%20-%20Anxiety%20Disorders. or β-blockers. delayed-onset PTSD is diagnosed. the person felt intense fear. ▪ TABLE 3-6 Diagnostic Criteria for Posttraumatic Stress Disorder Traumatic exposure Exposure to a traumatic circumstance in which both: 1.htm (13 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . efforts to avoid recollecting the trauma. SSRIs. DSM-IV criteria for PTSD are outlined in Table 3-6. Acute PTSD is diagnosed if symptoms have lasted less than 3 months. Sense of a foreshortened future (symptom 7 under Avoidance and Numbing) is a feeling that one's life is over and future plans are not of interest. Relaxation techniques are also used in treatment with some success. and hyperarousal. after 3 months.. horror. If the symptoms do not appear within 6 months of the stressor. an individual saw an event that involved actual or threatened loss of bodily integrity to the individual or to others 2. the duration of treatment is limited by the risk of tolerance and dependence. PTSD is considered chronic.. buspirone (a non-benzodiazepine anxiolytic). or helplessness file:///C|/Documents%20and%20Settings/ASUS/. gabapentin. PTSD PTSD is an anxiety disorder characterized by the persistent re-experience of a trauma. Although benzodiazepines are very effective.Ovid: Blueprints Psychiatry MANAGEMENT The pharmacologic treatment of GAD is with benzodiazepines.

conversations about the trauma 2. flashbacks. feeling detached/estranged from others 6. feeling as if the trauma were happening all over (reliving. foreshortened future file:///C|/Documents%20and%20Settings/ASUS/. avoiding activities. physiological reactivity upon exposure to cues that remind one of the event Avoidance and numbing Avoidance of reminders of the traumatic event and general emotional numbing (three or more of the following): 1.. distressing recurrent dreams of the event 3. thoughts. restricted range of emotions/affect 7. places. intense psychological distress upon exposure to cues that remind one of the event 5.Ovid: Blueprints Psychiatry Re-experiencing Traumatic event is re-experienced in one or more of the following ways: 1.. feelings. hallucinations) 4. or perceptions of the event 2.htm (14 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . or people that remind of the trauma 3. decreased interest in activities 5. avoiding thoughts.y/Chapter%203%20-%20Anxiety%20Disorders. illusions. distressing recurrent intrusive images. unable to recall important aspects of the trauma 4.

impaired concentration 4. ETIOLOGY The central etiologic factor in PTSD is the trauma..y/Chapter%203%20-%20Anxiety%20Disorders.5% among men and 1. Washington. sleep difficulty 2. file:///C|/Documents%20and%20Settings/ASUS/. EPIDEMIOLOGY The prevalence of PTSD is estimated at 0.2% among women. DC: American Psychiatric Association. hypervigilance 5. 2000. increased startle response Duration Symptoms last more than 1 month Impairment Significant impairment in functioning Adapted from the American Psychiatric Association. 4th ed. Diagnostic and Statistical Manual of Mental Disorders. There may be some necessary predisposition to PTSD because not all people who experience similar P. or even years after the initial trauma. Magnetic resonance imaging studies support a finding of altered hippocampal volume in PTSD. PTSD may occur at any age from childhood through adulthood and may begin hours. irritability/anger 3.htm (15 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ .22 traumas develop the syndrome.Ovid: Blueprints Psychiatry Increased arousal Persistent symptoms of increased physiological and mental arousal (requires two or more of the following): 1.. days.

Propranolol and other β-blockers may have a role in preventing the development of PTSD if given early after trauma. combat. numbing) or actual avoidance of circumstances that will evoke recall. panic disorder. if not.y/Chapter%203%20-%20Anxiety%20Disorders. Psychotherapy is effective and is typically tailored to the nature of the trauma. rape. and dissociative disorder. verify that there are also symptoms from all three categories. consider one of the previously mentioned diagnoses. They also experience feelings of detachment from others and exhibit evidence of autonomic hyperarousal. or were confronted with actual or potential death.. these patients make efforts to avoid recollections of the event. degree of coping skills. When symptoms resemble PTSD. MANAGEMENT Treatment is with a combination of symptomdirected psychopharmacologic agents and psychotherapy (individual or group).Ovid: Blueprints Psychiatry CLINICAL MANIFESTATIONS History and Mental Status Examination People with PTSD have endured a traumatic event (e. Tricyclic antidepressants and MAOIs may also be effective. GAD. or a threat to physical integrity. explosion) in which they experienced. dissociation.g. Differential Diagnosis Symptoms that resemble PTSD may be seen in depression.g.. hallucinations. OCD. ACUTE STRESS DISORDER file:///C|/Documents%20and%20Settings/ASUS/.. The traumatic event is subsequently re-experienced through repetitive intrusive images or dreams or through recurrent illusions. or flashbacks of the event. SSRIs used for at least 6 months appear to be the most effective treatment for reducing symptoms of PTSD. serious physical injury.htm (16 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . and the support systems available to the patient. physical assault. witnessed.. often through psychological mechanisms (e. In an adaptive attempt.

as the name implies. Neuroimaging evidence to date suggests that multiple brain regions are affected. Typical onset of the disorder is between the late teens and early 20s. self-limited condition lasting for a minimum of 2 days and a maximum of 4 weeks. This condition must also have its onset within 4 weeks of exposure to a traumatic event. but the diagnostic criteria are very similar to those for PTSD. Interestingly.htm (17 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry Acute stress disorder will not be reviewed in detail.y/Chapter%203%20-%20Anxiety%20Disorders. is an acute. head trauma. and twin studies show that monozygotic twins have a higher concordance rate than dizygotic twins. The major difference between a diagnosis of acute stress disorder and PTSD is chronicity. Table 3-7 outlines DSM-IV diagnostic criteria for this condition. The neurotransmitter serotonin has been implicated as a mediator in obsessive thinking and compulsive behaviors. Huntington's disease). CLINICAL MANIFESTATIONS file:///C|/Documents%20and%20Settings/ASUS/. An individual initially diagnosed with acute stress disorder could be subsequently diagnosed with PTSD if severe symptoms persist beyond 4 weeks after trauma exposure. EPIDEMIOLOGY The lifetime prevalence of OCD is 2% to 3%. OCD is seen more frequently after brain injury or disease (e. OCD OCD is an anxiety disorder in which patients experience recurrent obsessions and compulsions that cause significant distress and occupy a significant portion of their lives.. Acute stress disorder. ETIOLOGY Behavioral models of OCD claim that obsessions and compulsions are produced and sustained through classic and operant conditioning. these findings support a biologic basis for the disorder. seizure disorders.. but much additional research is needed in this regard.g.. but one-third of patients show symptoms of OCD before age 15. Treatment interventions during acute stress disorder may help prevent development of PTSD.

purposeful physical or mental actions that are generally performed in response to obsessions. diminish P. impulses. The compulsive “rituals” are meant to neutralize the obsessions. compulsions are repetitive. impulses.23 anxiety. and images The individual recognizes that the disturbing thoughts.htm (18 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ .. ▪ TABLE 3-7 Diagnostic Criteria for Obsessive Compulsive Disorder Obsessions or compulsions The individual has either obsessions or compulsions or both Obsessions Intrusive and inappropriate anxiety/distress-provoking thoughts. or somehow magically prevent a dreaded event or situation.y/Chapter%203%20-%20Anxiety%20Disorders. or images are not just excessive worry about real-life problems The individual attempts to control. or images that cause significant anxiety and distress. and images are coming from his/her own mind file:///C|/Documents%20and%20Settings/ASUS/. or images The disturbing thoughts. impulses.Ovid: Blueprints Psychiatry History and Mental Status Examination Patients with OCD experience obsessions and compulsions.. Obsessions are recurrent intrusive ideas. thoughts. or suppress the disturbing thoughts. ignore. impulses.

htm (19 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ .. Washington. they are not rationally associated with the desired outcome or are much in excess of what is necessary Insight The individual recognizes (at least at some point in the illness) that the obsessions or compulsions are excessive/unreasonable* Impairment The obsessions/compulsions caused marked distress and interfere and significantly impair normal functioning Specific The obsessions/compulsions are not better explained by another Axis 1.. Differential Diagnosis It is important to distinguish the obsessional thinking of OCD from the delusional thinking of schizophrenia or other file:///C|/Documents%20and%20Settings/ASUS/. then the diagnosis of OCD * with poor insight is made. 4th ed.y/Chapter%203%20-%20Anxiety%20Disorders. Diagnostic and Statistical Manual of Mental Disorders. medical. DC: American Psychiatric Association.Ovid: Blueprints Psychiatry Compulsions Driven repetitive behaviors or mental acts involving rules or in response to obsessions Although the behaviors/mental acts are aimed at lowering distress or preventing a feared outcome. Adapted from the American Psychiatric Association. 2000. or drug-related condition If the person does not recognize the unreasonable nature of the obsessions/compulsions.

whereas delusions are generally regarded as distinct from patients' thoughts and are typically not resisted... P. activity.Ovid: Blueprints Psychiatry psychotic disorders. and SSRIs have been shown to be quite effective in treating OCD. Although poorly studied. file:///C|/Documents%20and%20Settings/ASUS/. and response prevention have been used successfully to treat compulsive rituals.24 KEY POINTS ● Panic disorder can be seen with or without agoraphobia and is characterized by recurrent unexpected panic attacks. ● Specific phobia is an intense fear of a specific object. place. and recognized by patients as coming from their own thoughts. ● Panic disorder is treated with antidepressants and benzodiazepines and cognitive-behavioral techniques. someone who fears contamination from an object will hold the object repeatedly in therapy while simultaneously being prevented from carrying out the ritual associated with the dreaded object. flooding.htm (20 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ . Obsessions are usually unwanted. resisted. the behavioral techniques of systematic desensitization. or situation and occurs in 25% of the population at some point.y/Chapter%203%20-%20Anxiety%20Disorders. clomipramine. MANAGEMENT CBT. For example.

● PTSD is treated with medications directed at specific symptoms and with psychotherapy. ● OCD is treated with CBT. SSRIs. SSRIs. file:///C|/Documents%20and%20Settings/ASUS/. buspirone. and response prevention.. clomipramine. ● OCD is a distressing condition characterized by recurrent obsessions and compulsions. systematic desensitization. difficult-to-control worry over every aspect of life associated with physical manifestations of anxiety. alprazolam. flooding. ● Treatment is with MAOIs. gabapentin.. SSRIs. efforts to avoid recalling the trauma. and hyperarousal. or gabapentin and with CBT. and relaxation techniques. ● GAD is an intense. β-blockers.htm (21 of 21) [30/01/2009 06:21:25 ‫]ﻡ‬ .y/Chapter%203%20-%20Anxiety%20Disorders. β-blockers.Ovid: Blueprints Psychiatry Social phobia is fear of exposure to scrutiny by others and has a lifetime prevalence of 3% to 5%. ● PTSD occurs as a response to trauma and is characterized by re-experience of the trauma. ● GAD is treated with benzodiazepines.

much contemporary research approaches them as dimensional. and aggression as having their roots in ancient neural structures related to the limbic system (especially the amygdala. and anxious and fearful (Table 4-1). dopamine. file:///C|/Documents%20and%20Settings/ASUS/M. Michael J. An individual may use multiple defense mechanisms. There are three recognized personality disorder clusters: odd and eccentric. and cingulate gyrus) (Fig. Although the DSM-IV criteria for personality disorders are categorical..hapter%204%20-%20Personality%20Disorders. 4th edition (DSM-IV). Personality disorders frequently overlap in symptoms. DSM-IV general diagnostic criteria for personality disorders are outlined in Table 4-2.. impulsivity..Ovid: Blueprints Psychiatry Authors: Murphy. 2004) embrace more dimensions of personality structure including affective instability. Table 4-3 indicates the primary ego defense mechanisms (see Chapter 17 on Psychological Theory for discussion of ego defense mechanisms) found in a subset of personality disorders. Goodman et al. More recent scientifically grounded theories have emphasized the role of neurobiology and evolutionary psychology in personality disorders. Ten types of personality disorders are grouped into clusters based on similar overall characteristics. Cowan. emerging theories support the role of physical and emotional trauma in producing borderline personality disorder in vulnerable individuals. Current evidence supports an interaction of genetics and environment in producing personality.. As a useful mnemonic. norepinephrine) with the expression of those symptoms modulated by more recently evolved brain regions such as the neocortex and neurotransmitters such as γ-aminobutyric acid and glutamate. and cognitive factors.g. Ronald L. anxiety. aggression. it is helpful to consider the origins of particular symptoms. Criteria for individual personality disorders are discussed below.htm (1 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . such as fear.Personality Disorders Chapter 4 Personality Disorders Personality disorders are coded on Axis II in the Diagnostic and Statistical Manual of Mental Disorders. anger. NEURAL BASIS Earlier psychoanalytic theories focused on the role of infantile development in personality disorders. however. dramatic and emotional. hippocampus. Title: Blueprints Psychiatry. Brain imaging studies support the presence of altered brain structure and function in some personality disorders. Some theorists (Lara and Akiskal. Others (e. anxiety. In particular. 4-1) and the monoamine neurotransmitters (serotonin. 2006) consider fear and anger traits as the core dysregulated emotions in personality disorders. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 4 .

betrayal.5% to 2..Ovid: Blueprints Psychiatry CLUSTER A (ODD AND ECCENTRIC) PARANOID PERSONALITY DISORDER People with paranoid personality disorder are distrustful. They require emotional distance. suspicious. file:///C|/Documents%20and%20Settings/ASUS/M. and deception.5% of the general population.hapter%204%20-%20Personality%20Disorders. suspicious. Not surprisingly. they are not forthcoming about themselves. Epidemiology Paranoid personality disorder has a lifetime prevalence of 0. and anticipate harm and betrayal. There appears to be a small increase in prevalence among relatives of individuals with schizophrenia. P.. and see the world as malevolent. Clinical Manifestations History and Mental Status Examination People with paranoid personality disorder are distrustful. Family studies suggest a link to delusional disorder (paranoid type).26 ▪ TABLE 4-1 Classification of Personality Disorders Cluster A (Odd/Eccentric) Paranoid Schizoid Schizotypal Cluster B (Dramatic/Emotional) Antisocial Borderline Histrionic Narcissistic Cluster C (Anxious/Fearful) Avoidant Dependent Obsessive-compulsive Etiology Environmental precursors are unclear.htm (2 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . They anticipate harm. Relatives of patients with chronic schizophrenia and patients with persecutory delusional disorders show an increased prevalence of paranoid personality disorder.

Washington.. DC: American Psychiatric Association. Deviates markedly from cultural expectations Is inflexible and personally and socially pervasive Causes distress or social or work impairment Is a stable pattern of experience and behavior of long duration (“stably unstable”) Cannot be explained by another mental illness Is not caused by substance use or medical condition Note: Individuals with personality disorders usually maintain intact reality testing. acting out Dissociation Isolation Differential Diagnosis The key distinction is to separate paranoia associated with psychotic disorders from paranoid personality disorder. ▪ TABLE 4-3 Primary Ego Defense Mechanisms in Some Personality Disorders Disorder Paranoid personality disorder Schizoid personality disorder Borderline personality disorder Histrionic personality disorder Obsessive-compulsive personality disorder Defense Projection Fantasy Splitting. 3.hapter%204%20-%20Personality%20Disorders.Ovid: Blueprints Psychiatry ▪ TABLE 4-2 Diagnostic Criteria for Personality Disorders Patients with personality disorder evidence an enduring pattern of inner experience and behavior. 2. Reproduced with permission from the American Psychiatric Association. 4th ed.htm (3 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . SCHIZOID PERSONALITY DISORDER file:///C|/Documents%20and%20Settings/ASUS/M. especially because paranoia associated with psychotic disorders is generally responsive to antipsychotic medications. Personality disorders are different from personality traits that are typically adaptive. but they may have transient psychotic symptoms when stressed by real (or imagined) loss or frustration. 5. 4. 2000. established by adolescence or early adulthood. that: 1. culturally acceptable.. 6. and do not cause significant distress or impairment. Diagnostic and Statistical Manual of Mental Disorders.

Major limbic system structures involved in mediating many normal functions and those dysregulated in psychiatric disorders. Etiology There is some evidence to suggest increased prevalence of schizoid personality disorder in relatives of persons with schizophrenia or schizotypal personality disorder. and interconnected structures may be important in many components of personality disorders. but because people with schizoid personality disorder are avoidant of others. Clinical Manifestations History and Mental Status Examination These people are loners. (Courtesy of the Anatomical Chart Company. Epidemiology Estimates of lifetime prevalence range as high as 7. they may maintain an important bond with a family member.27 Figure 4-1 • Limbic system neuroanatomy. They are aloof and detached and have profound difficulty experiencing or expressing emotion. cingulate gyrus. they are not commonly seen in clinical practice. The amygdala. Although they prefer to be left alone and generally do not seek relationships.hapter%204%20-%20Personality%20Disorders.htm (4 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . hippocampal formation..) Differential Diagnosis file:///C|/Documents%20and%20Settings/ASUS/M.5% of the general population..Ovid: Blueprints Psychiatry Individuals with schizoid personality disorder are emotionally detached and prefer to be left alone. P. especially those characterized by anxiety/fear and anger/aggression.

Ovid: Blueprints Psychiatry Schizoid personality disorder can be distinguished from avoidant personality disorder (see later) and social phobia by the fact that schizoid individuals do not desire relationships. perception. and belief. Epidemiology file:///C|/Documents%20and%20Settings/ASUS/M. Many are highly distrustful and often paranoid. Clinical Manifestations History and Mental Status Examination Schizotypal personality disorder is best thought of as similar to schizophrenia but less severe and without sustained psychotic symptoms. perceptions. autistic disorder.. Epidemiology Lifetime prevalence is 3% of the general population. Differential Diagnosis Schizophrenia. which results in a very constricted social world. and mood disorder with psychosis are the major differential diagnoses.hapter%204%20-%20Personality%20Disorders. The lifetime suicide rate among this population is 10%. but their anxiety handicaps their capacity to achieve relatedness. SCHIZOTYPAL PERSONALITY DISORDER Individuals with schizotypal personality disorder have odd thoughts. and beliefs. especially among first-degree relatives of individuals with schizophrenia.htm (5 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . People with this disorder have few relationships and demonstrate oddities of thought. delusional disorder. and Asperger's disorder (a less severe variant of autism) are also differential diagnostic conditions. Etiology Studies demonstrate interfamilial aggregation of this disorder. Avoidant and socially phobic persons desire and may seek relationships.. CLUSTER B (DRAMATIC AND EMOTIONAL) ANTISOCIAL PERSONALITY DISORDER Individuals with antisocial personality disorder (ASP) repetitively disregard the rules and laws of society and rarely experience remorse for their actions. Schizophrenia. affect. affects.

BORDERLINE PERSONALITY DISORDER Individuals with borderline personality disorder suffer from instability in relationships. Their lifetime suicide rate is 5%. Females with borderline personality disorder frequently have suffered from sexual or physical abuse or both. this disorder shows increased rates in families of alcoholics and families of individuals with ASP. Differential Diagnosis Bipolar disorder and substance abuse disorder can prompt antisocial behaviors during the acute illness.. are impulsive and aggressive. Alcoholism is a frequently associated finding in this population. conversely. They are exploitative. violent. is not state dependent. which remit when the disorder is controlled. endanger others. Many individuals with ASP are indicted or jailed for their actions. whereas women have higher rates of somatization disorder. In families of an individual with ASP. About half have been arrested. self-image. file:///C|/Documents%20and%20Settings/ASUS/M. about half of those in prison have ASP.. lie frequently. affect. A harsh. as well as in families with mood disorders. In addition. and rarely P. Clinical Manifestations History and Mental Status Examination Individuals with ASP display either a flagrant or well-concealed disregard for the rules and laws of society. Etiology ASP is more common among first-degree relatives of those diagnosed with ASP.htm (6 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ .28 experience remorse for the harm they cause others. and criminal environment also predisposes people to this disorder.Ovid: Blueprints Psychiatry ASP is present in 3% of men and 1% of women. and impulse control. The antisocial behavior of individuals with ASP. men show higher rates of ASP and substance abuse. Etiology Borderline personality disorder is about five times as common among first-degree relatives of borderline patients.hapter%204%20-%20Personality%20Disorders. Epidemiology Lifetime prevalence is 1% to 2% of the general population.

Clinical Manifestations History and Mental Status Examination Individuals with histrionic personality disorder are characterized by their excessive and superficial emotionality and their profound need to be the center of attention at all times.. mood disorders. fragmented.. projection. The principal intrapsychic defenses such individuals use are primitive with gross denial. the diagnosis is most frequently applied to women but may equally affect men in the general population. distortion. promiscuity. Etiology There appears to be a familial link to somatization disorder and to ASP. and values. exaggerated file:///C|/Documents%20and%20Settings/ASUS/M. HISTRIONIC PERSONALITY DISORDER Individuals with histrionic personality disorder have excessive superficial emotionality and a powerful need for attention. depression. The diagnostic clues are unstable relationships. unstable affect. Their relationships are infused with anger.htm (7 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . including substance abuse.hapter%204%20-%20Personality%20Disorders. unstable self-image. and eating disorders. Epidemiology Lifetime prevalence is 2% to 3% of the general population.Ovid: Blueprints Psychiatry Clinical Manifestations History and Mental Status Examination Individuals with borderline personality disorder suffer from a legion of symptoms. with anger. Their impulsiveness can result in many unsafe behaviors. fear of abandonment. In clinical settings. and unstable or impulsive behaviors. and suicide rates approach 10% over a lifetime. Their self-destructive urges result in frequent suicidal and parasuicidal behavior (such as superficial cutting or burning or nonfatal overdoses in which the intent is not lethal). and shifting idealization and devaluation. and panic prominent. Suicide attempts can be frequent before the age of 30. They also demonstrate brief paranoia and dissociative symptoms. Theatrical behavior dominates with lively and dramatic clothing. and other risk-taking behavior. Differential Diagnosis Mood disorders and behavioral changes resulting from active substance abuse are the principal differential diagnostic considerations. They are affectively unstable and reactive. Their self-image is inchoate. and unstable with consequent unpredictable changes in relationships. gambling. goals. Patients may exhibit a broad range of comorbid illnesses. and splitting prominent. including drug use.

29 across a wide variety of circumstances. worthy.. and inappropriate flirtatious and seductive behavior P. and they demand attention and admiration. however. Etiology The etiology of this disorder is unknown.htm (8 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . Clinical Manifestations History and Mental Status Examination People with narcissistic personality disorder demonstrate an apparently paradoxical combination of self-centeredness and worthlessness. exploitative. They often appear arrogant. Differential Diagnosis Somatization disorder is the principal differential diagnostic consideration. Despite their apparent plethora of emotion. Differential Diagnosis The grandiosity of narcissism can be differentiated from the grandiosity of bipolar disorder by the presence of characteristic mood symptoms in bipolar disorder. these individuals often have difficulty with intimacy. Epidemiology Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.hapter%204%20-%20Personality%20Disorders. Up to 50% to 75% of those with this diagnosis are men. NARCISSISTIC PERSONALITY DISORDER Individuals with narcissistic personality disorder appear arrogant and entitled but suffer from extremely low self-esteem. and entitled. or able.. frequently believing their relationships are more intimate than they actually are. Despite their inflated sense of self. Their sense of self-importance is generally extravagant.Ovid: Blueprints Psychiatry emotional responses to seemingly insignificant events. Concern or empathy for others is typically absent. CLUSTER C (ANXIOUS AND FEARFUL) file:///C|/Documents%20and%20Settings/ASUS/M. below their brittle facade lies low self-esteem and intense envy of those whom they regard as more desirable.

. Epidemiology Lifetime prevalence is 0. Etiology There are no conclusive data.Ovid: Blueprints Psychiatry AVOIDANT PERSONALITY DISORDER Individuals with avoidant personality disorder desire relationships but avoid them because of the anxiety produced by their sense of inadequacy. 2% to 3% clinically. They are painfully sensitive to criticism.30 Etiology The etiology is unknown.htm (9 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . and consequent social inhibition. The pattern of avoidance may start in infancy. Differential Diagnosis The major diagnostic distinction is between avoidant personality disorder and social phobia. hypersensitivity to criticism. DEPENDENT PERSONALITY DISORDER Individuals with dependent personality disorder are extremely needy. generalized type. Their fears of rejection and humiliation are so powerful that to engage in a relationship..5% to 1% of the general population and appears to be equally prevalent in men and women. relying on others for emotional support and decision making. The essence of this disorder is inadequacy. they seek strong guarantees of acceptance. Epidemiology Lifetime prevalence is 15% to 20%. file:///C|/Documents%20and%20Settings/ASUS/M. Clinical Manifestations History and Mental Status Examination People with avoidant personality disorder experience intense feelings of inadequacy. so much so that they are compelled to avoid spending time with people.hapter%204%20-%20Personality%20Disorders. P.

and poor self-image of the borderline patient. Etiology The etiology is unknown. OBSESSIVE-COMPULSIVE PERSONALITY DISORDER These individuals are perfectionists who require a great deal of order and control. They are cold and rigid in relationships and make frequent moral judgments. but there may be an association with mood and anxiety disorders..htm (10 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ .. Because of their extreme dependence on others for emotional support and decision making. Their attention to minutiae frequently impairs their ability to finish what they start or to maintain sight of their goals. They are serious and plodding.hapter%204%20-%20Personality%20Disorders.Ovid: Blueprints Psychiatry Clinical Manifestations History and Mental Status Examination These people yearn to be cared for. devotion to work often replaces intimacy. Clinical Manifestations History and Mental Status Examination Individuals with obsessive-compulsive personality disorder are perfectionists. Men are diagnosed with obsessive-compulsive personality disorder twice as frequently as women. Differential Diagnosis People with dependent personality disorder are similar to individuals with borderline personality disorder in their desire to avoid abandonment but do not exhibit the impulsive behavior. even recreation becomes a sober task. Management file:///C|/Documents%20and%20Settings/ASUS/M. Differential Diagnosis Obsessive-compulsive personality disorder can be differentiated from obsessive-compulsive disorder based on symptom severity. unstable affect. they live in great and continual fear of separation from someone they depend on. hence their submissive and clinging behaviors. Epidemiology The estimated prevalence is 1% in the general population. They require order and control in every dimension of their lives.

Benzodiazepines are commonly used for anxiety. Dialectical behavioral therapy was developed specifically for the treatment of borderline personality disorder and has been validated in empirical studies. P.31 KEY POINTS ● Personality disorders are categorized into three symptom clusters. and eating disturbances. psychotherapy is recommended for most personality disorders. For example. Group therapy incorporating various psychotherapeutic modalities is also used. and family therapies are also used to treat these disorders. obsessive-compulsive symptoms. Instead. file:///C|/Documents%20and%20Settings/ASUS/M. ● Personality disorders are resistant to treatment. For depression. behavioral. ● The disorders can produce transient psychotic symptoms during stress. medications are targeted at the various associated symptoms of personality disorders. mood stabilizers may be used for mood instability and impulsiveness. ● Personality disorders consist of an enduring pattern of experience and behavior. In general.htm (11 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ . Empirical studies validating the efficacy of various therapies are generally lacking. Cognitive. selective serotonin-reuptake inhibitors and other antidepressants have been successfully used. β-blockers are also used frequently.. Psychotic or paranoid symptoms are commonly treated with low-dose antipsychotics.Ovid: Blueprints Psychiatry Because personality may have temperamental components and is developed over a lifetime of interacting with the environment.hapter%204%20-%20Personality%20Disorders. Pharmacotherapy is widely used in personality disorders. personality disorders are generally resistant to treatment. Psychodynamically based therapies are commonly used. although the potential for abuse and dependence is too often overlooked. although they must be modified to each individual and each disorder. ● Treatment is with psychotherapy and medications targeted at symptom relief. although no specific medication has been shown to treat any specific disorder..

Ovid: Blueprints Psychiatry ● Personality disorders may have genetic associations with Axis 1 disorders.htm (12 of 12) [30/01/2009 06:21:30 ‫]ﻡ‬ .hapter%204%20-%20Personality%20Disorders... file:///C|/Documents%20and%20Settings/ASUS/M.

4th edition (DSM-IV) defines substance abuse and dependence independent of the substance. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 5 . It is etiologic for many medical illnesses and is frequently comorbid with psychiatric illness. Hence.Substance-Related Disorders Chapter 5 Substance-Related Disorders Substance abuse is as common as it is costly to society..htm (1 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ .. or work ● Recurrent substance use in situations in which it is physically hazardous ● Recurrent substance-related legal problems ● Recurrent substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance file:///C|/Documents%20and%20Settings/ASUS/M. Cowan. Michael J.Ovid: Blueprints Psychiatry Authors: Murphy. Title: Blueprints Psychiatry. alcohol abuse and dependence is defined by the same criteria as heroin abuse and dependence. Ronald L. SUBSTANCE ABUSE The DSM-IV defines substance abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following: ● Failure to fulfill major role obligations at home.. Here the common substance-related disorders are reviewed in sequence. The DSM-IV recognizes the different signs and symptoms associated with various drug addictions. The Diagnostic and Statistical Manual of Mental Disorders. This chapter defines abuse and dependence and provides clinical descriptions of each substance-related disorder.%205%20-%20Substance-Related%20Disorders. school.

33 file:///C|/Documents%20and%20Settings/ASUS/M. these are considered the common features that define substance dependence. excessive use ● Persistent failed efforts to cut down ● Excessive time spent trying to obtain the substance ● Reduction in important social. a disorder develops when a person is biologically vulnerable.htm (2 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . and is repeatedly exposed to the substance with ongoing availability.%205%20-%20Substance-Related%20Disorders. NEURAL BASIS As with all psychiatric disorders. occupational. has access to the substance. and functional brain disorders are rooted firmly in neurobiology. or recreational activities ● Continued use despite awareness that substance is the cause of psychological or physical difficulties Although each substance dependence disorder has unique features. Substance use disorders develop through a biopsychosocial interaction whereby genetic effects and environment interact to culminate in a behavioral pattern of repeated drug use.Ovid: Blueprints Psychiatry SUBSTANCE DEPENDENCE Substance dependence is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress. In addition to biological vulnerabilities that pre-exist P.. Although the degree to which genetic factors explain the risk for abuse of or dependence on a particular substance vary. unintended.. Major substance use disorders are discussed with particular attention to their unique features. as manifested by three or more of the following occurring at any time in a 12-month period: ● Tolerance ● Withdrawal ● Repeated. substance use disorders are structural.

Ovid: Blueprints Psychiatry the use of a particular substance. Naturally occurring rewards having high evolutionary adaptive significance (such as feeding. Philadelphia: Lippincott Williams & Wilkins. and current evidence suggests that addictive substances or behaviors (including nicotine. Figure 5-1 • The mesolimbic dopamine system. sex. (Reproduced with permission from Bear MF. Neuroscience—Exploring the Brain. The mesolimbic dopamine system consists of dopaminergic axons arising from the ventral tegmental area (VTA) that ascend via the medial forebrain bundle to innervate the ventral striatum. and additional limbic structures.htm (3 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ .) The specific brain effects of a given drug vary with the chemical composition of that drug. 2001.%205%20-%20Substance-Related%20Disorders. and exercise) interact with the mesolimbic dopamine pathway to produce associative memories linked to the rewards that reinforce the probability of rewarding behavior.. exposure of the brain to the drug has secondary consequences whereby the direct chemical effects of the drug change brain structure and function with repeated exposure. This structure is a target of the mesolimbic dopamine pathway that mediates reward system function (Fig. and perhaps sex and gambling) act by a final common pathway influencing neurons of the ventral striatum/nucleus accumbens. food. Drugs of abuse bypass the adaptive components of the reward system file:///C|/Documents%20and%20Settings/ASUS/M. 2nd ed. Parasido MA. Connors BW. caffeine. prefrontal cortex. 5-1)..

ALCOHOL USE DISORDERS ALCOHOL DEPENDENCE Alcohol abuse becomes alcohol dependence when effects on one's life become more global and tolerance and withdrawal symptoms develop. exposure to drug cues. 1996. 248. p. motivation.Ovid: Blueprints Psychiatry and. there is also a persistent desire or unsuccessful efforts to cut down or control alcohol intake. Drugs of abuse influence neurons of the nucleus accumbens (ventral striatum) largely through actions on the dopamine neurons of the ventral tegmental area (VTA). 5-2).htm (4 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . 1. The alcohol-dependent patient drinks larger amounts over longer periods of time than intended.) that predispose to relapse. In alcohol dependence. produce similar powerful associative memories strongly reinforcing behavior associated with drug use (Fig. Figure 5-2 • Sites of action of drugs of abuse. must include an awareness of the nonconscious factors (such as stress. etc. or recreational activities because of alcohol. Treatment for addiction. there are conscious and nonconscious elements predisposing to continued drug use despite adverse consequences of the drug. occupational.. and reduces participation in or eliminates important social. and attention.) Because addiction occurs when repeated exposure to drugs has produced alterations in the brain's reward system and in other brain regions involved in craving. via direct synaptic effects.34 deal of time attempting to obtain alcohol. Fig. hunger. (Adapted from Wise. spends a great P. file:///C|/Documents%20and%20Settings/ASUS/M. therefore..%205%20-%20Substance-Related%20Disorders.

hypertension. pancreas. The male to female prevalence ratio for alcohol dependence is 4:1. tuberculosis. Wernicke-Korsakoff's syndrome may develop in the alcohol-dependent patient because of thiamine deficiency. and painless hepatomegaly (from fatty infiltration). The Epidemiological Catchment Area study found a lifetime prevalence of alcohol dependence of 14%. and hepatic encephalopathy. oral. making the early diagnosis of alcoholism difficult.%205%20-%20Substance-Related%20Disorders. Medical disorders with an increased incidence in alcohol-dependent patients include pneumonia. jaundice. colon. ascites. Etiology The etiology of alcohol dependence is unknown. or after an arrest for driving under the influence.e. palmar erythema.Ovid: Blueprints Psychiatry Epidemiology The percentage of Americans who abuse alcohol is thought to be high. drinking almost every day and becoming intoxicated several times a month. esophageal. 12% are heavy drinkers. The patient may present with accidents or falls. and liver). Adoption studies and monozygotic twin studies demonstrate a partial genetic basis.. motor vehicle accidents. Early physical findings that suggest alcohol dependence include acne rosacea. Adoption studies also reveal that alcoholism is multidetermined: genetics and environment (family rearing) both play a role.. and Dupuytren contracture. The Wernicke's stage of the syndrome is also called Wernicke's encephalopathy (note: Wernicke's encephalopathy is a type of neurological syndrome that is not listed among the file:///C|/Documents%20and%20Settings/ASUS/M. rectal. cardiomyopathy. Two-thirds of Americans drink occasionally. and gastrointestinal cancers (i. hepatocellular carcinoma. the relatives of alcoholics are more likely to have higher rates of depression and antisocial personality disorder.htm (5 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . testicular atrophy. Clinical Manifestations History The alcohol-dependent patient may deny or minimize the extent of drinking. gynecomastia. collateral information from family members is essential to the diagnosis. Because denial is so prominent in the disorder. Physical Examination Signs of more advanced alcohol dependence include cirrhosis. particularly for men with alcoholism. Compared with control subjects. Cirrhosis can lead to complications including variceal bleeding. Male alcoholics are more likely than female alcoholics to have a family history of alcoholism. blackouts. Mental Status Examination There are also numerous neuropsychiatric complications of alcohol dependence..

In the later stages of alcoholism.%205%20-%20Substance-Related%20Disorders. mental status. compared with 1% of control subjects..htm (6 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . ataxia. Management Management is specific to the clinical syndrome. and elevated serum glutamic-pyruvic transaminase. Note also that the DSM-IV does not use Korsakoff's syndrome/psychosis as a diagnostic entity but considers it to be synonymous with alcohol-induced persisting amnestic disorder. alcohol-induced dementia. Differential Diagnosis The diagnosis of alcohol dependence is usually clear after careful history. or if there is concern that the patient may have thiamine deficiency. changes due to subdural hematoma or other intracranial bleeding. They can also provide a rough measure of tolerance. and suicide. If oral intake is not possible. P. Blood alcohol levels quantitatively confirm alcohol in the serum. have evidence of old rib fractures on chest radiographs. Alcohol intoxication is treated with supportive measures. All suspected or known alcohol-dependent patients should receive oral vitamin supplementation with folate 1 mg per day and thiamine 100 mg per day. recent malnutrition. Of alcohol-dependent patients. however. elevated serum glutamicoxaloacetic transaminase. then thiamine should file:///C|/Documents%20and%20Settings/ASUS/M. In general.. substance-induced depression. few patients with Wernicke's syndrome display the complete triad. significant social and occupational impairment is likely: job loss and family estrangement are typical. 30%. and mental confusion. Other neuropsychiatric complications of alcoholism include alcoholic hallucinosis.Ovid: Blueprints Psychiatry DSM-IV alcohol-related diagnoses). peripheral neuropathy. and is thought to be on a continuum with Korsakoff's syndrome/psychosis. the higher the blood alcohol level without significant signs of intoxication.35 the more tolerant the patient has become of the intoxicating effects of alcohol. physical and mental status examination. It is associated with alcohol dependence. Management of Wernicke's encephalopathy is covered in the information to follow. and consultation with family or friends. or early signs of Wernicke's encephalopathy. Intensive care may be required in cases of excessive alcohol intake complicated by respiratory compromise. Korsakoff's syndrome/psychosis is thought to occur after an acute episode of Wernicke's encephalopathy and may reflect the long-term brain damage resulting from thiamine deficiency. Laboratory Tests Various laboratory tests are helpful in making the diagnosis. including decreasing external stimuli and withdrawing the source of alcohol. and the diagnosis of Wernicke's syndrome may be missed in up to 90% of clinical presentations. however. malabsorption. Wernicke's encephalopathy consists of the triad of eye movement abnormalities. Alcohol-dependent patients also develop elevated mean corpuscular volume.

When alcohol withdrawal is complicated by hallucinations or perceptual alterations with intact reality testing and with other signs of delirium. ALCOHOL WITHDRAWAL The complexity and time course of alcohol withdrawal cannot be fully captured in a descriptive narrative. and intoxication with benzodiazepines or barbiturates. mood lability. The diagnosis of alcohol intoxication must be differentiated from other medical or neurologic states that may mimic intoxication. Table file:///C|/Documents%20and%20Settings/ASUS/M. toxicity with various agents. Grand mal seizures may also occur. sensory disturbances (perceptual distortions. Along with delirium and Wernicke's encephalopathy. impaired social or occupational functioning) that develop during or shortly after alcohol ingestion. incoordination. Clinical signs of alcohol withdrawal include tremor (especially of the hands). and phenytoin. lithium. gastrointestinal symptoms (nausea and vomiting). Wernicke's encephalopathy may progress to a chronic condition of alcohol-induced persisting amnestic disorder (information to follow). unsteady gait. for example. These symptoms may remit with the slow intravenous infusion of thiamine at 400 to 500 mg per day for 4 to 5 days. and clinically significant maladaptive behavioral or psychological changes (inappropriate sexual or aggressive behavior. grand mal seizures are among the most serious complications of alcohol withdrawal.%205%20-%20Substance-Related%20Disorders. The DSM-IV criteria for alcohol withdrawal basically include the cessation of alcohol intake after a period of prolonged heavy use and withdrawal signs. diabetic hypoglycemia. sweating). psychomotor agitation. including but not limited to ethylene glycol. hallucinations). cardiovascular symptoms (tachycardia. Magnesium repletion is also essential. ALCOHOL-INDUCED DISORDERS ALCOHOL INTOXICATION Alcohol intoxication is defined by the presence of slurred speech. including a blood alcohol level. nystagmus.. then alcohol withdrawal with perceptual disturbances is diagnosed. hypertension. impairment in attention or memory.. Without thiamine at sufficiently high dosages and given intravenously. As noted. and caregivers should be wary of assumptions regarding alcohol withdrawal. stupor or coma. and anxiety. insomnia. the evolution of alcohol withdrawal can have a variable time course and does not necessarily progress in fixed order.htm (7 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . then alcohol withdrawal delirium is diagnosed. Alcohol withdrawal commonly occurs with a predictable course but may show much individual variation.Ovid: Blueprints Psychiatry be administered intravenously as a slow infusion before any glucose is given (because glucose depletes thiamine stores). When alcohol withdrawal is complicated by delirium. impaired judgment. The diagnosis of alcohol intoxication can be confirmed by serum toxicologic screening.

Treatment may need to occur in an intensive care unit. and impaired executive function.%205%20-%20Substance-Related%20Disorders. confusion or disorientation.. and mild fever. particularly if there is significant autonomic instability (e. It is treated with intravenous benzodiazepines and supportive care. ▪ TABLE 5-1 Alcohol Withdrawal Sign or Symptom Tremulousness (the shakes) Perceptual disturbances Seizures Delirium Onset* 4-12 hours 8-12 hours 12-24 hours 72 hours * Onset refers to the onset following the cessation of alcohol intake after a prolonged period of heavy regular drinking. Alcohol-induced persisting amnestic disorder is also called Korsakoff's syndrome and is irreversible in two-thirds of patients. The diagnosis is made when alcohol is determined to be the cause of the cognitive changes. making file:///C|/Documents%20and%20Settings/ASUS/M. apraxia. It affects up to 5% of hospitalized patients with alcohol dependence and typically begins 2 to 3 days after abrupt reduction in or cessation of alcohol intake.. rapidly fluctuating blood pressure). aphasia.g. This is more accurately tied to the point at which alcohol blood levels decline.36 (perceptual disturbances. consisting of deficits in memory. ALCOHOL-INDUCED PERSISTING DEMENTIA The criteria for alcohol-induced persisting dementia are similar to other types of dementias in terms of the cognitive deficits.Ovid: Blueprints Psychiatry 5-1 summarizes the time course of alcohol withdrawal symptoms. Alcohol-induced persisting amnestic disorder is diagnosed in an individual with a history of alcohol dependence who develops memory impairment in learning new memories or recalling old information..htm (8 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . ALCOHOL-INDUCED PERSISTING AMNESTIC DISORDER Alcohol-induced persisting amnestic disorder is also classified as an amnestic disorder under the heading of substance-induced persisting amnestic disorder. The syndrome typically lasts 3 days but can persist for weeks.e. autonomic hyperarousal. or agnosia. agitation).. Confabulation (i. ALCOHOL WITHDRAWAL DELIRIUM Alcohol withdrawal delirium (delirium tremens) is a life-threatening condition manifested by delirium P.

has been shown to be one of the most effective programs for achieving and maintaining sobriety. so that acetaldehyde accumulates in the bloodstream. palpitations. disulfiram should inhibit drinking by making it physiologically unpleasant. a worldwide self-help group for recovering alcohol-dependent patients. Members are expected to pursue the 12 steps with the assistance of a sponsor (preferably someone with several years of sobriety). Inpatient and residential rehabilitation programs use a team approach aimed at focusing the patient on recovery. In theory. however. vomiting. because the effects can be fatal in rare cases. Alcohol appears to be a potent cause of depression. The usual dose of disulfiram is 250 mg daily. and alcohol-induced sleep disorder. ALCOHOL REHABILITATION The two goals of rehabilitation are sobriety and treatment of comorbid psychopathology. Naltrexone (Revia) is an opiate antagonist medication.Ovid: Blueprints Psychiatry up information to fill gaps in memory) is common. Disulfiram (Antabuse) can be helpful in maintaining sobriety in some patients. alcohol-induced anxiety disorder. Anxiety is also common in withdrawing or newly sober patients and should be assessed after at least 1 month of sobriety. These include alcohol intoxication delirium.htm (9 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . It acts by inhibiting the second enzyme in the pathway of alcohol metabolism.. Intoxicated patients may appear severely depressed and display suicidal behavior or statements. Family therapy allows the patient to examine the role of the family in alcoholism. nausea. Naltrexone reduces both the amount of alcohol intake and the frequency of file:///C|/Documents%20and%20Settings/ASUS/M.37 and fully understand the danger of drinking while taking disulfiram. alcohol-induced sexual dysfunction. patients must be committed to abstinence P. and hypotension. several other disorders can be produced by alcohol exposure.. Treatment of depression should be geared to patients who remain depressed after 2 to 4 weeks of sobriety. ADDITIONAL DISORDERS In addition to the alcohol-induced disorders just discussed. causing flushing.%205%20-%20Substance-Related%20Disorders. To sustain a lasting recovery. alcohol-induced mood disorder. alcohol-induced psychotic disorder with delusions. Group therapy allows patients to see their own problems mirrored in and confronted by others. aldehyde dehydrogenase. the patient must stop denying the illness and accept the diagnosis of alcohol dependence. alcohol-induced psychotic disorder with hallucinations. Alcoholics Anonymous (AA). The program involves daily-to-weekly meetings that focus on 12 steps toward recovery. which resolve when sobriety is achieved.

EPIDEMIOLOGY Approximately 15% of the general population is prescribed a benzodiazepine in a given year.. SEDATIVE. Many studies have demonstrated benefits from rehabilitation programs. hypnotic. It is important to differentiate these drugs from other drugs used for sleep induction and from other medications used in psychiatry to treat anxiety. but higher doses may potentially be more effective. Some patients abuse these drugs. Naltrexone is usually dosed at 50 mg per day. Unlike disulfiram. and acamprosate are used for maintenance therapy and do not prevent the potentially life-threatening symptoms of alcohol withdrawal. and withdrawal delirium that resemble those of alcohol. Naltrexone. the benzodiazepines are the most widely prescribed and available. acamprosate does not produce a disulfiram-like effect and can be continued in persons who relapse to alcohol consumption. Physical and Mental Status Examinations file:///C|/Documents%20and%20Settings/ASUS/. naltrexone. serotonin reuptake inhibitor antidepressants and buspirone are first-line treatments for some types of anxiety but are not classified here. Acamprosate (Campral) is a glutamate receptor modulator (and may also affect γ-aminobutyric acid) medication used for the maintenance of alcohol abstinence and in reducing the rate and severity of relapse. hypnotic. AND ANXIOLYTIC SUBSTANCE USE DISORDERS Sedative.. as an opioid antagonist. patients can continue taking naltrexone if they relapse to alcohol intake. Included in this class are barbiturates and benzodiazepines. and anxiolytic drugs refers to only barbiturates and benzodiazepines that share in common augmentation of γ-aminobutyric acid function. Note that this section for sedative. and anxiolytic drugs are widely used. most commonly in the first 6 months. withdrawal. Like naltrexone.205%20-%20Substance-Related%20Disorders. but nearly half of all treated alcohol-dependent patients will relapse.htm (10 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . HYPNOTIC. They are all cross-tolerant with each other and with alcohol. The barbiturate and benzodiazepines can produce a life-threatening withdrawal syndrome.Ovid: Blueprints Psychiatry alcohol intake. Of these. may work in part by reducing the reinforcing “high” of alcohol ingestion. CLINICAL MANIFESTATIONS History Sedative-hypnotic drug abuse and dependence are associated with syndromes of intoxication. It is important to note that disulfiram. In particular.

Dependence requires the presence of three or more of the seven symptoms listed in Table 5-2. barbiturates. Withdrawal delirium (confusion.38 half-life of the drug in question. whereas withdrawal from longer-acting substances is more prolonged. in the serum. are much more likely than benzodiazepines to cause clinically significant respiratory compromise. as it can (much more easily) lead to hyperpyrexia.. ▪ TABLE 5-2 Signs and Symptoms of Sedative-Hypnotic Withdrawal Minor Withdrawal Restlessness Apprehension Anxiety More Severe Withdrawal Coarse tremors Weakness Vomiting Sweating Hyperreflexia Nausea Orthostatic hypotension Seizures MANAGEMENT Treatment of sedative-hypnotic withdrawal may be on an outpatient or inpatient basis. hypnotic.. disorientation. Generally. benzodiazepines or barbiturates may be administered and tapered in a controlled manner. Withdrawal from short-acting substances is generally more severe. or lack of support by family or friends. Barbiturates. when taken orally.htm (11 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . and visual and somatic hallucinations) has an onset as early as 3 to 4 days after abstinence depending on the P. Laboratory Tests Intoxication can be confirmed through quantitative or qualitative serum or urine toxicologic analyses. inpatient detoxification is required when there is comorbid medical or psychiatric illness. or urine. Withdrawal from barbiturates is more dangerous than from benzodiazepines. On an inpatient unit.Ovid: Blueprints Psychiatry Sedative. prior treatment failures. file:///C|/Documents%20and%20Settings/ASUS/. Withdrawal symptoms are listed in Table 5-2. Serum toxicologic screens can identify the presence of benzodiazepines. and their major metabolites. or anxiolytic intoxication can be distinguished from alcohol intoxication by the presence (or absence) of alcohol on the breath.205%20-%20Substance-Related%20Disorders.

After detoxification. Opiates are commonly used for pain control. and constipation are common after opiate use. Nausea. EPIDEMIOLOGY Opiate use and abuse are relatively uncommon in the United States. Many of those who use opiates recreationally become addicted. and prescription pain reliever dependence is about 0. an AA-focused family education and support group. bradycardia. which produces flushing and an intensely pleasurable. Withdrawal is managed by scheduled dosing and tapering of a benzodiazepine or barbiturate (diazepam or phenobarbital). and hydromorphone. codeine. and hypothermia. This test allows for the quantification of tolerance to perform a controlled taper. vomiting. Referral to AA is appropriate because the addiction issues and recovery process are similar. Families may be referred to Al-Anon. OPIOID USE DISORDERS Opiates include morphine.1%. drowsiness..205%20-%20Substance-Related%20Disorders. Heroin is available only illegally in the United States.6%. it may be necessary to perform a pentobarbital challenge test. In patients who have been abusing alcohol and benzodiazepines or barbiturates. Laboratory Tests Opiate use can be confirmed by urine or serum toxicological measurements.. Treatment of sedative-hypnotic dependence resembles that for alcohol dependence. CLINICAL MANIFESTATIONS History Most heroin and morphine users take opiates intravenously. slurred speech.htm (12 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry seizure. and impaired concentration ensue. heroin. This initial “rush” is followed by a sense of well-being. Prevalence for heroin dependence is about 0. Physical and Mental Status Examinations Signs of intoxication occur immediately after the addict “shoots up” and include pupillary constriction. and death. the patient can enter a residential rehabilitation program or a day or evening treatment program. Psychomotor retardation. inactivity. diffuse bodily sensation that resembles orgasm. hypotension. meperidine. respiratory depression. thereby reducing the problems of withdrawal. file:///C|/Documents%20and%20Settings/ASUS/.

39 Opiate addicts often have comorbid substance use disorders.205%20-%20Substance-Related%20Disorders. MANAGEMENT file:///C|/Documents%20and%20Settings/ASUS/. antisocial or borderline personality disorders. and restlessness Nausea Vomiting Lacrimation or rhinorrhea Pupillary dilatation Piloerection Sweating Tachycardia Fever Diarrhea Insomnia Yawning Abdominal cramps Hypertension Hot and cold flashes Severe anxiety Muscle aches Seizures (in meperidine withdrawal) More Severe Withdrawal P. ▪ TABLE 5-3 Symptoms of Opiate Withdrawal Mild Withdrawal Dysphoric mood. Withdrawal symptoms are listed in Table 5-3. endocarditis. pneumonia. Opiate addicts are more prone to commit crimes because of the high cost of opiates. Withdrawal symptoms usually begin 10 hours after the last dose.. Common medical disorders include serum hepatitis. Opiate addiction is also associated with high mortality rates from inadvertent overdoses. Differential Diagnosis The diagnosis of opiate addiction is usually obvious after a careful history as well as mental status and physical examinations.. human immunodeficiency virus infection. and mood disorders. and suicide. accidents. Addicts “shoot up” three or more times per day.htm (13 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . In addition. In opiate dependence. opiate addicts are at higher risk of medical problems because of poor nutrition and use of dirty needles.Ovid: Blueprints Psychiatry Opiate abuse is defined by the criteria for substance abuse previously noted. and cellulitis. users develop a tolerance to the effects of opiates. anxiety. Withdrawal from opiates can be highly uncomfortable but is rarely medically complicated or life-threatening.

Clonidine. In the United States. Withdrawal from short-acting opiates lasts 7 to 10 days. Cocaine has an extremely rapid onset of action (when snorted or smoked) and a short half-life. a 12-step program similar to AA.. Methadone maintenance. which is typically smoked. which is typically snorted and as cocaine alkaloid crystal (“crack”). Buprenorphine (Buprenex) is a µ opioid receptor partial agonist and a κ opioid receptor antagonist. Approval of the tablet form of buprenorphine permitted the expansion of the treatment of opioid dependence beyond that of methadone clinics. Generally. and quinine for muscle aches.” In the United States. Methadone is a weak agonist of the µ opiate receptor and has a longer half-life (15 hours) than heroin or morphine. The patterns of use and abuse of and dependence on cocaine and amphetamines are similar because both are central nervous system stimulants with similar psychoactive and sympathomimetic effects.205%20-%20Substance-Related%20Disorders. Risks of sedation and hypotension limit the usefulness of clonidine in outpatient settings. It is remarkably effective at treating the autonomic symptoms of withdrawal but does little to curb the drug craving. promethazine for nausea. Long-term administration of methadone can alleviate drug hunger and minimize drug-seeking behavior. it causes relatively few intoxicant or withdrawal effects.Ovid: Blueprints Psychiatry Patients addicted to opiates should be gradually withdrawn using methadone. Buprenorphine tablets as Subutex (buprenorphine alone) or as Suboxone (buprenorphine plus naltrexone) are FDA approved for outpatient treatment of opioid dependence by certain qualified physicians. the initial dose of methadone (typically 5 to 20 mg) is based on the profile of withdrawal symptoms. Inclusion of naltrexone with buprenorphine in Suboxone allows the administration of opiate replacement therapy with decreased euphoric and respiratory depressant effects. requiring frequent dosing to remain “high. an amphetamine (dextroamphetamine) and methylphenidate are available in pill form by prescription for file:///C|/Documents%20and%20Settings/ASUS/. cocaine is available in two forms: as cocaine hydrochloride powder.htm (14 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . daily administration of 60 to 100 mg of methadone in government-licensed methadone clinics.. Thus. Injectable buprenorphine is employed as an off-label use for opiate detoxification. withdrawal from longer-acting meperidine lasts 2 to 3 weeks. Clonidine does not appear to be as effective as opiate replacement in helping maintain abstinence. such as dicyclomine for abdominal cramping. a centrally acting α-2 receptor agonist that decreases central noradrenergic output. can also be used for acute withdrawal syndromes. is used widely for patients with demonstrated physiologic dependence. Additional medications can be used to relieve uncomfortable symptoms of withdrawal. CENTRAL NERVOUS SYSTEM STIMULANT USE DISORDERS Cocaine and amphetamines are readily available in the United States. Rehabilitation generally involves referral to an intensive day treatment program and to Narcotics Anonymous.

are generally superior to the selective serotonin reuptake inhibitors in the treatment of cocaine-related depression.. euphoria or hypervigilance) ● Tachycardia or bradycardia ● Pupillary dilatation ● Hyper. Amphetamines have a longer half-life than cocaine and hence are taken less frequently. P..htm (15 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ .g. Various forms of amphetamine are used illicitly including a very pure form of methamphetamine. respiratory depression. chest pain.or hypotension ● Perspiration or chills ● Nausea or vomiting ● Psychomotor agitation or retardation ● Muscular weakness. and attention-deficit/hyperactivity disorder.205%20-%20Substance-Related%20Disorders. which can be snorted or smoked.Ovid: Blueprints Psychiatry the treatment of obesity. narcolepsy. cardiac dysrhythmias ● file:///C|/Documents%20and%20Settings/ASUS/. Rates of depression are generally higher in substance-abusing and substance-dependent individuals..40 CLINICAL MANIFESTATIONS Cocaine or amphetamine intoxication is characterized by: ● Maladaptive behavioral changes (e. Antidepressant medications influencing catecholamine function. such as desipramine and bupropion. called crystal methamphetamine.

Ovid: Blueprints Psychiatry Confusion. dyskinesia. It is important to note that drug use trends can change rapidly. profuse sweating. Narcotics Anonymous.. CLUB DRUGS Club drugs are a group of drugs classified by the National Institute on Drug Abuse according to their popularity in dance clubs and other party venues. Both cocaine and amphetamine intoxication can lead to agitation. Psychosis from amphetamine intoxication or withdrawal is generally self-limited. MANAGEMENT Withdrawal from amphetamines or other central nervous system stimulants is self-limited and usually does not require inpatient detoxification. CANNABIS AND MISCELLANEOUS SUBSTANCE USE DISORDERS CANNABIS Cannabis is widely used throughout the world in the forms of marijuana and hashish. Ultimately.. and existing drugs may go in or out of fashion. and hunger. visual hallucinations).g.. seizures. Complications of cannabis include impaired judgment. muscle cramps. requiring only observation in a safe environment. poor concentration. Antipsychotic medications can be used to treat agitation.4-methylenedioxy-N-methylamphetamine [MDMA]) is a widely popular drug with mixed stimulant and hallucinogenic file:///C|/Documents%20and%20Settings/ASUS/. Cocaine and amphetamine dependence is defined by the criteria outlined above for substance dependence. Because of their popularity and tendency for users to show up in emergency rooms.205%20-%20Substance-Related%20Disorders. paranoia. and poor memory. Cannabis withdrawal syndromes are self-limited and do not require psychiatric or medical treatment. impaired judgment. The drug is usually smoked and causes a state of euphoria. the goal is rehabilitation. Withdrawal of cocaine or amphetamines leads to fatigue. These drugs are of a wide variety of chemical classes but are linked by their frequent use in social groups and the fact that they are commonly taken together. treatment of comorbid psychopathology. and transient psychosis (e. Withdrawal symptoms peak in 2 to 4 days.htm (16 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . Serious complications include delirium and psychosis. New drugs may also emerge at any time. and family therapy are the essential features of cocaine rehabilitation. depression. Ecstasy Ecstasy (3. the following information reviews some of the more widely used club drugs. headache. nightmares. or coma Cocaine intoxication can cause tactile hallucinations (coke bugs). administration of drugs to reduce craving.

htm (17 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ .. file:///C|/Documents%20and%20Settings/ASUS/.. The latest survey results from the National Survey on Drug Use and Health (U.to 25-year-old age group. It is used for its hallucinatory. ketamine is a dissociative anesthetic mostly used in veterinary medicine.) indicate about 5% to 6% of people have used methamphetamine in their lifetime with rates greatest in the 18. γ-Hydroxybutyrate γ-hydroxybutyrate (GHB) is a compound used in lower doses by bodybuilders and others seeking to P. Methamphetamine is often produced locally in small laboratories and can therefore vary greatly in purity.S. Long-term MDMA use appears to lead to a long-lasting reduction in serotonin transmission throughout the brain. Ketamine Also known as Special K. and MDMA appears specifically to enhance the user's desire for intimacy with others. and it may be a frequent culprit in drugging others for the purpose of theft or sexual assault. dissociative effect. Many users report a stimulant and euphoric effect. Long-term LSD use can lead to psychosis or hallucinogen persisting perception disorder. Acute use of MDMA has been associated with deaths from various causes. GHB is used to produce a high and is common among the club and party scene. Acute use can produce a highly euphoric (good trip) or a highly dysphoric (bad trip) hallucinatory experience. its use has been associated with an increased frequency of unsafe sexual activity. GHB dependence may occur. Rohypnol produces classic benzodiazepine effects of sedation. GHB is easily overdosed and can lead to death from respiratory arrest. It has strong amnestic properties.41 gain muscle mass (GHB promotes the release of growth hormone). and withdrawal requires medical management. methamphetamine is a psychostimulant that is neurotoxic to dopamine and serotonin axons. Lysergic Acid Diethylamide Lysergic acid diethylamide (LSD) is famous for its hallucinogenic properties. Methamphetamine Also known as crystal or crank.205%20-%20Substance-Related%20Disorders. Rohypnol Rohypnol is a benzodiazepine approved for clinical use in some countries outside the United States.Ovid: Blueprints Psychiatry properties. As such. however. In higher doses.

g. is aimed at abstinence and treating comorbid disorders. hepatitis. ● file:///C|/Documents%20and%20Settings/ASUS/. denial and minimization are common. pneumonia. ● Peak incidence of alcoholic seizures is within 24 to 48 hours. ● Wernicke's triad consists of nystagmus. ataxia. and accidents. ● Cocaine and amphetamines are central nervous system stimulants and can cause transient psychosis (e. and withdrawal states are similar to alcohol.Ovid: Blueprints Psychiatry KEY POINTS ● In alcohol dependence. ● Sedatives and hypnotic drugs are cross-tolerant with alcohol. endocarditis. ● Alcohol-induced persisting amnestic disorder (Korsakoff's) symptoms result from brain damage due to thiamine deficiency and include amnesia and confabulation. coke bugs or paranoia). suicide. involving AA and therapy. and mental confusion. and cellulitis with high mortality rates from accidental overdose. ● Opiate addicts are at increased risk of human immunodeficiency virus..htm (18 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ . ● Opiate withdrawal is uncomfortable but not usually medically complicated.205%20-%20Substance-Related%20Disorders. ● Benzodiazepines are used in acute detoxification to prevent life-threatening complications of withdrawal... ● Rehabilitation.

depression. nightmares..Ovid: Blueprints Psychiatry Stimulant withdrawal symptoms (fatigue. etc.) are self-limited and peak in 2 to 4 days. file:///C|/Documents%20and%20Settings/ASUS/..205%20-%20Substance-Related%20Disorders.htm (19 of 19) [30/01/2009 06:21:38 ‫]ﻡ‬ .

NEURAL BASIS Although the different types of eating disorders do not share a single neurobiological origin. If ideal body weight is maintained in the presence of abnormal eating behaviors.. Ronald L. serotonergic dysfunction is strongly associated with these conditions and with associated symptoms. Eating disorders likely lie along a continuum of disturbances in eating behavior and often are associated with mood disorders and other psychiatric illnesses (Table 6-1). Regions mediating feeding file:///C|/Documents%20and%20Settings/ASUS/M. High comorbidity with obsessive-compulsive disorder and body image disturbances (body dysmorphic disorder) suggests overlap with brain regions affected in these conditions.. norepinephrine. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 6 . and opiate systems are also implicated. The principal diagnostic distinction is based on ideal body weight. Cowan. many symptoms overlap. Alterations in dopamine. a diagnosis of anorexia nervosa is made. Hypothalamic and limbic neural regions. 4th edition (DSM-IV). When abnormal eating behavior causes body weight to fall below a defined percentage of expected body weight. Title: Blueprints Psychiatry.Ovid: Blueprints Psychiatry Authors: Murphy. neuropeptide. Although eating disorders are classified into two discrete diagnostic categories in the Diagnostic and Statistical Manual of Mental Disorders. Michael J. a diagnosis of bulimia nervosa is made..try/Chapter%206%20-%20Eating%20Disorders. including the reward system likely play a role.htm (1 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ .Eating Disorders Chapter 6 Eating Disorders Eating disorders are characterized by disturbances in eating behavior and an overconcern with body image or size.

and commonly display “all-or-none” thinking. The prevalence in men is not clear.g. and insula are also likely affected. Psychological theories of anorexia nervosa remain speculative. difficulty with self-esteem. Contemporary theories focus on the need to control one's body. EPIDEMIOLOGY The point prevalence of anorexia nervosa is between 0. Although it is not specific to eating disorders. file:///C|/Documents%20and%20Settings/ASUS/M.. such as nucleus accumbens. anorexia nervosa has been present during periods when societal mores for beauty were different. Anorexia nervosa is more common in industrial societies and higher socioeconomic classes.. ETIOLOGY Eating disorders and their subtypes likely share many common bases of origin. Social theories propose that societal opinions. past physical or sexual abuse may be a risk factor. historically.htm (2 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ . The weight loss must result from behavior directed at maintaining low weight or achieving a particular body image. drive women to develop eating disorders..5% and 1% in women. The average age of onset is 17. Patients with anorexia nervosa generally have a high fear of losing control. which equate low body weight with attractiveness. Anorexia nervosa is diagnosed when a person's body weight falls below 85% of the ideal weight for that individual. P.try/Chapter%206%20-%20Eating%20Disorders. Although this fact may be responsible for some cases (e. and more than 90% of patients with anorexia nervosa are women.43 anorexia nervosa is more common among dancers and models). orbitofrontal cortex. ANOREXIA NERVOSA Anorexia nervosa is a severe eating disorder characterized by low body weight.Ovid: Blueprints Psychiatry behavior. with onset rare before puberty or after age 40.

CLINICAL MANIFESTATIONS History and Mental Status Examination DSM-IV criteria for the diagnosis of anorexia nervosa include refusal to keep body weight at greater than 85% of ideal. familial. Twin studies show higher concordance for monozygotic versus dizygotic twins. and genetic data support a biologic and heritable basis for anorexia. Amenorrhea is also a diagnostic criterion in postmenarchal females (delay of menarche may occur in premenarchal girls).. and the denial of the medical risks of low weight. preoccupation with body size and shape. Neuroendocrine evidence supporting a biologic contribution to anorexia includes alterations in corticotropin-releasing factor. and that amenorrhea (caused by decreased luteinizing hormone and follicle-stimulating hormone release) sometimes precedes the onset of anorexia nervosa. they refuse to eat out of fear of gaining weight.Ovid: Blueprints Psychiatry ▪ TABLE 6-1 Classification of Eating Disorders Anorexia Nervosa Restricting type Binge eating/purging type Bulimia Nervosa Nonpurging type Purging type Biologic. an intense fear of weight gain.try/Chapter%206%20-%20Eating%20Disorders.htm (3 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ . Family studies reveal an increased incidence of mood disorders and anorexia nervosa in first-degree relatives of patients with anorexia nervosa.. reduced central nervous system norepinephrine metabolism. In some cases. amenorrhea precedes file:///C|/Documents%20and%20Settings/ASUS/M. a disproportionate influence of body weight on personal worth. Patients with anorexia nervosa generally do not have a loss of appetite.

psychotherapy is of little value because of the cognitive impairment produced by starvation. or induced vomiting) to control weight. weight and electrolyte monitoring.. These include major depression with loss of appetite and weight. in most cases. these must be carefully treated and followed. the major methods of weight control are food restriction and exercise.try/Chapter%206%20-%20Eating%20Disorders..htm (4 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ . Individuals with anorexia nervosa commonly exercise intensely to lose weight and alter body shape. but many cases become chronic. but binge eating and subsequent purging behaviors are also present. The long-term mortality rate of anorexia nervosa secondary to suicide or medical complications is estimated at 7% to 10%. Differential Diagnosis Conditions that can resemble anorexia should be ruled out. it appears to be a consequence of starvation. others use binging and purging (use of laxatives. diuretics. The natural course of anorexia is not well understood. a therapeutic program including supervised meals. When patients are less medically ill. MANAGEMENT The management of anorexia nervosa is directed at the presenting symptoms. enemas. food restriction and exercise may be present.Ovid: Blueprints Psychiatry the development of anorexia nervosa. however. Anorexia nervosa is differentiated from bulimia nervosa by the presence of low weight in individuals with the former. some psychotic disorders in which nutrition may not be adequate. Some restrict food intake as a primary method of weight control. and a variety of general medical (especially neuroendocrine) conditions. ipecac toxicity must be ruled out. The behavioral repertoire used to control body weight is used to classify anorexia nervosa further into two subtypes: restricting type and binging/purging type. In the restricting type. During starvation. If ipecac use to induce vomiting is suspected. When medical complications are present. body dysmorphic disorder. In the binging/purging type. file:///C|/Documents%20and%20Settings/ASUS/M.

The male:female ratio is 1:10.Ovid: Blueprints Psychiatry psychoeducation about the illness. Psychopharmacology management often includes antidepressants. EPIDEMIOLOGY The estimated point prevalence of bulimia nervosa is 1% to 3% of women. Psychopharmacologic treatments are used principally to treat any comorbid psychiatric illness and have little or no effect on the anorexia per se. individual psychotherapy. and nutrition. and endocrine findings are less prominent in theories of causation of bulimia nervosa. Familial and genetic studies support similar familial linkages in both disorders.44 BULIMIA NERVOSA Bulimia nervosa is an eating disorder characterized by binge eating with the maintenance of body weight. neurologic. and family therapy can begin. Abnormal serotonin metabolism is thought to play more of a role in bulimia nervosa than in anorexia nervosa. starvation.. especially the selective serotonin reuptake inhibitors to treat comorbid depression. This illness occurs disproportionately among whites in the United States. P.try/Chapter%206%20-%20Eating%20Disorders. CLINICAL MANIFESTATIONS History and Mental Status Examination Bulimia nervosa is diagnosed in individuals who engage in binge eating and behaviors designed to avoid weight gain file:///C|/Documents%20and%20Settings/ASUS/M..htm (5 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ . Biologic. ETIOLOGY Many of the factors in the genesis of anorexia nervosa are also implicated in bulimia nervosa. Psychological theories for bulimia nervosa stress an addiction or obsessive-compulsive behavioral model.

Bulimia nervosa is classified into two subtypes: nonpurging type or purging type (Table 6-1) according to whether purging behavior is present. these are people whose self-evaluation is overly influenced by their body weight and shape. at times.Ovid: Blueprints Psychiatry but who maintain their body weight. Purging may follow and most often consists of vomiting. Individuals with bulimia often exercise and restrict their food intake. Once a binge begins.. Other purging methods used to avoid weight gain include laxative and diuretic abuse and enemas. Self-esteem and interpersonal relationships become the focus of therapy as the behavioral problems abate. MANAGEMENT The treatment for bulimia nervosa is similar to that for anorexia nervosa. Psychotherapy focuses at first on achieving control of eating behavior. patients with bulimia nervosa are overly concerned with body image and are preoccupied with becoming fat. As in anorexia nervosa. In addition. are more effective in the treatment of bulimia nervosa than in anorexia nervosa (including patients who do not have file:///C|/Documents%20and%20Settings/ASUS/M. usually induced mechanically by stimulating the gag reflex or using ipecac. If body weight is less than 85% of ideal. the individual typically feels out of control and continues to eat large quantities of food. especially selective serotonin reuptake inhibitors.htm (6 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ . Binge eating can occur in major depression and in borderline personality disorder.. other medical complications can require careful medical management and. a diagnosis of anorexia nervosa is made. but it is not tied to a compulsion to reduce weight. Cognitive therapy may be useful in treating overconcern with body image. Food binges in bulimia nervosa may be precipitated by stress or altered mood states.try/Chapter%206%20-%20Eating%20Disorders. hospitalization. Differential Diagnosis Bulimia nervosa should be distinguished from the binge eating and purging subtype of anorexia nervosa. Antidepressants. Although medical complications of starvation are not present. often to the point of physical discomfort.

it is unknown for bulimia nervosa.. Table 6-2 lists the common medical complications of eating disorders. and severe mood disturbance. In addition to these medical complications. and cause tremendous suffering and burden for their families. and eventual cardiovascular collapse.try/Chapter%206%20-%20Eating%20Disorders. and mental status changes are important during refeeding. congestive heart failure.htm (7 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ . Medical Complications Chronic eating disorders can have serious medical consequences both with and without treatment. and cardiac arrhythmias secondary to electrolyte imbalance (particularly hypokalemia as a result of recurrent purging). gastric or esophageal rupture. can be fatal. The lifetime mortality rate from anorexia nervosa is approximately 10%. ▪ TABLE 6-2 Medical Complications of Eating Disorders file:///C|/Documents%20and%20Settings/ASUS/M. cardiomyopathy from ipecac toxicity.. secondary psychiatric and neurologic sequellae include cognitive decline. Gradual refeeding with monitoring of P. metabolic encephalopathy. seizures. Treatment of severely underweight (less than 75% ideal body weight) patients with anorexia can lead to a refeeding syndrome: a state caused by sudden carbohydrate intake severely depleting body phosphate stores (hypophosphatemia) resulting in rhabdomyolysis. delirium. take a severe toll on the patient's overall functioning. all with profound consequences for patients and their families.Ovid: Blueprints Psychiatry comorbid depression). The most serious of these.45 serum potassium and phosphate can prevent the complication. Other complications of eating disorders parallel those of chronic medical illness. Looking for signs of edema.

file:///C|/Documents%20and%20Settings/ASUS/M. anemia Increased ventricular/brain ratio Hypotension..try/Chapter%206%20-%20Eating%20Disorders. lanugo hair Prevention Focus on preventing mental illness has led to research on interventions that might decrease the incidence or severity of eating disorders. metabolic alkalosis (with cardiac arrhythmias) Ipecac toxicity (cardiac and skeletal myopathies) Laxative use Constipation (caused by laxative dependence) Metabolic acidosis Dehydration Diuretic use Electrolyte abnormalities (with cardiac arrhythmias) Dehydration Starvation Leukopenia.. hypochloremic.Ovid: Blueprints Psychiatry Behavior Binge eating Gastric dilatation or rupture Obesity Vomiting Esophageal rupture Medical Complication Parotiditis with hyperamylasemia Hypokalemic. bradycardia Hypothermia Hypercholesterolemia Edema Dry skin.htm (8 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ .

file:///C|/Documents%20and%20Settings/ASUS/M. ● Bulimia nervosa is a severe eating disorder characterized by binge eating and purging. denial. One study has shown that providing a cognitive therapy-oriented educational module to at-risk young women decreased the incidence of eating disorders over a 5-year follow-up period.Ovid: Blueprints Psychiatry A number of modifiable risk factors for eating disorders have been identified including familial focus on weight and appearance. body image distortion. and the influence of media portrayals of body type. life transitions.. fear of gaining weight. and has a greater than 10% long-term mortality rate.. and amenorrhea. ● Anorexia nervosa is diagnosed more than 90% of the time in women. ● Bulimia nervosa is also characterized by maintenance of normal body weight. including refeeding syndrome.htm (9 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ . presence of mood or anxiety disorder. certain athletic or entertainment professions. ● Anorexia nervosa can cause serious medical complications. KEY POINTS ● Anorexia nervosa is characterized by failure to maintain normal body weight.try/Chapter%206%20-%20Eating%20Disorders. ● Bulimia nervosa is more common in women than in men.

.Ovid: Blueprints Psychiatry ● Bulimia nervosa can have serious medical complications.. file:///C|/Documents%20and%20Settings/ASUS/.htm (10 of 10) [30/01/2009 06:21:43 ‫]ﻡ‬ .ry/Chapter%206%20-%20Eating%20Disorders.

Child psychiatric assessment requires attention to details of a child's stage of development. mood. usually express emotion in a more concrete (less abstract) way than adults.g. Title: Blueprints Psychiatry. motor. and psychotic seen in adults can occur in children. This chapter reviews only the more common disorders. however. family structure and dynamics. and imaginative play are often used to gain insight into the child's emotional and interpersonal life.rs%20of%20Childhood%20and%20Adolescence. and other involved parties (e. Consequently. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 7 . including anxiety.htm (1 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ .. a sign of possible mental disorder in children. there is a group of disorders usually first diagnosed in children. Cowan. Department of Social Services/Youth Services) are essential to proper assessment. Playing games. observations are also made regarding activity level.. These behaviors can be used to screen for abnormal psychomotor development. Table 7-2 outlines developmental milestones in social.. “Are you sad?”). Table 7-1 lists these disorders according to the Diagnostic and Statistical Manual of Mental Disorders. Children are much more likely than adults to have comorbid mental disorders. motor skills.. taking turns telling stories. During play. Consulting with parents and obtaining information from schools. Ronald L.Ovid: Blueprints Psychiatry Authors: Murphy. and language functions. teachers. file:///C|/Documents%20and%20Settings/ASUS/. especially young children. making diagnosis and treatment more complicated. and normative age-appropriate behavior. and verbal expression. child interviews require more concrete queries (“Do you feel like crying?” instead of. Children. Michael J. 4th edition (DSM-IV).Disorders of Childhood and Adolescence Chapter 7 Disorders of Childhood and Adolescence Many disorders.

The WISC-R is the most widely used intelligence test for assessing school-age children. An IQ of less than 70 is required for the diagnosis of mental retardation.rs%20of%20Childhood%20and%20Adolescence. Because seizure activity or subtle electroencephalographic abnormalities are common in certain child psychiatric disorders. P. or Adolescence file:///C|/Documents%20and%20Settings/ASUS/. The evaluation of mental retardation usually involves a search for possible causes. impulsiveness. It yields a verbal score. Tests of general intelligence include the Stanford-Binet Intelligence Scale (one of the first intelligence tests developed and often used in young children) and the Wechsler Intelligence Scale for Children-Revised (WISC-R). MENTAL RETARDATION Patients with mental retardation have subnormal intelligence (as measured by IQ) combined with deficits in adaptive functioning. and personality style (by describing what is happening in an ambiguous scene).htm (2 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . perceptual-motor skills (by drawing people.47 ▪ TABLE 7-1 Disorders Usually First Diagnosed in Infancy. Childhood.Ovid: Blueprints Psychiatry The complexities of diagnosis in child psychiatry often require the use of psychological testing. IQ is defined as the mental age (as assessed using a WISC-R) divided by the chronologic age and multiplied by 100.. then the ratio equals 1 and the IQ is 100. placing pegs in appropriately shaped holes). physical activity). an electroencephalogram (EEG) may be warranted. There are many other tests and objective rating scales designed to measure behavior (e.. a performance score. and a fullscale score (both verbal and performance) or intelligence quotient (IQ). If mental age equals chronologic age. Severity ranges from mild to profound and is based on IQ (Table 7-3)..g.

.htm (3 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry Mental Retardation Learning Disorders Reading disorder Mathematics disorder Disorder of written expression Motor Skills Disorder Developmental coordination disorder Communication Disorders Expressive language disorder Mixed receptive-expressive language disorder Phonological disorder Stuttering Pervasive Developmental Disorders Autistic disorder Rett's disorder Childhood disintegrative disorder Asperger's disorder Attention-Deficit and Disruptive Behavior Disorders Attention-deficit/hyperactivity disorder Conduct disorder Oppositional defiant disorder Feeding and Eating Disorders of Infancy or Early Childhood Pica file:///C|/Documents%20and%20Settings/ASUS/.rs%20of%20Childhood%20and%20Adolescence..

Most patients with mental retardation have mild or moderate forms (Table 7-3). perinatal or early childhood head injuries. Inborn errors of metabolism. Childhood.htm (4 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . Fragile X syndrome is the most common cause of heritable mental retardation. more severe forms of mental retardation are independent of socioeconomic status. ETIOLOGY Mental retardation can be thought of as a final common pathway of a number of childhood or perinatal disorders. or Adolescence Separation anxiety disorder Selective mutism Reactive attachment disorder of infancy or early childhood Stereotypic movement disorder EPIDEMIOLOGY Mental retardation affects 1% to 2% of the population and has a male:female ratio of 2:1. The most common cause of mental retardation is Down's syndrome (trisomy 21).Ovid: Blueprints Psychiatry Rumination disorder Feeding disorder of infancy or early childhood Tic Disorders Tourette's disorder Chronic motor or vocal tic disorder Transient tic disorder Elimination Disorders Encopresis Enuresis Other Disorders of Infancy. Milder forms of mental retardation occur more frequently in families with low socioeconomic status.rs%20of%20Childhood%20and%20Adolescence. maternal file:///C|/Documents%20and%20Settings/ASUS/...

48 ▪ TABLE 7-2 Developmental Milestones file:///C|/Documents%20and%20Settings/ASUS/.g. communication.. toxemia.. delayed speech.Ovid: Blueprints Psychiatry diabetes. Laboratory findings may suggest metabolic or chromosomal etiology.. or self-care skills capacity) or on scoring an IQ less than 70 on the Stanford-Binet (usually only for very young children) or WISC-R (standard for school-age children). and Laboratory Tests Most mentally retarded children have physical malformations that identify them at birth as being at high risk for mental retardation (such as the characteristic facies of the child with Down's syndrome). interpersonal skills). The onset of symptoms must be before age 18. Physical and Mental Status Examinations. self-care. The patient must have both an IQ less than or equal to 70 and concurrent deficits or impairments in several areas of adaptive functioning (e.htm (5 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . or rubella can all cause mental retardation. Parents or pediatricians may identify young children with mental retardation after failure to meet developmental milestones in a number of functional areas (e.. In 30% to 40% of patients with mental retardation. no clear etiology can be determined.g. P. social skills. CLINICAL MANIFESTATIONS History.rs%20of%20Childhood%20and%20Adolescence. Overall. there are more than 500 genetic abnormalities associated with mental retardation. substance abuse. Infants can show signs of significantly subaverage intellectual functioning.

makes scribble marks understands command with gesture Combines two words. rolls objects prone to supine reciprocally 6 months Sits unsupported Reaches with one hand.. points to body parts Vocabulary of 50 to 300 words. plays peek-a-boo (gesture games) 12 months Walks Voluntarily releases Uses one to four words.. Uses fork and kicks ball spoon.to eightblock tower 3 years Alternates feet on stairs Copies circle Uses five. uses two. vocalizes prone position. builds seven.to eight-word Knows name/age/gender. parallel play 2 years Jumps with two feet.Ovid: Blueprints Psychiatry Gross Motor 3 months Fine Motor Language Cognitive/Social/Adaptive Recognizes parent.to three-word phrases Imitates.htm (6 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ .rs%20of%20Childhood%20and%20Adolescence. throws a ball. anticipates feeding Raises chest/head in Pointing motions at Coos.” “ma-ma”) Stranger anxiety.” grasping object imitates sounds (“da-da. rakes with all fingers Babbles Attached to primary caregiver 9 months Pulls to standing Rotates hand when Understands “no. cooperates with dressing 18 months Walks up stairs. items. runs Builds three-block tower Names pictures. understands sentences. 75% of language is understandable to strangers cold/tired/hungry file:///C|/Documents%20and%20Settings/ASUS/. plays near other children Removes simple clothing.

Fine K. 2009. including IQ testing. depression. and seizure disorder can all resemble mental retardation. an EEG. Blueprints Pediatrics. washes and dries hands 5 years Skips with alternating feet Draws a person with Asks meaning of words six body parts.rs%20of%20Childhood%20and%20Adolescence. McMillan JA. Philadelphia: Lippincott. Philadelphia: Lippincott Williams & Wilkins. Children suspected of having mental retardation should have a thorough medical and neurologic evaluation. P. 4th ed. learning disorders. Feigin RD. schizophrenia. These disorders can also be comorbid conditions. De Angelis CD.. Oski's Pediatrics: Principles & Practice. understands and abides by rules. copies a triangle Names four colors. Williams & Wilkins. 100% of language is recognizable Puts on shoes. cooperative play Adapted from Marino B. 5th ed. and brain imaging (computerized tomography or magnetic resonance imaging).Ovid: Blueprints Psychiatry 4 years Balances on one foot Catches a ball.htm (7 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . et al. T96-1.49 file:///C|/Documents%20and%20Settings/ASUS/. copies a square Tells a story. T96-2.. ▪ TABLE 7-3 Mental Retardation Degree of Mental Retardation Mild Moderate Severe Profound IQ Percentage of Total Mentally Retarded Population 50-70 85% 35-50 10% 20-35 3%-4% <20 1%-2% Differential Diagnosis Attention-deficit/hyperactivity disorder (ADHD). T4-1.

most of these children will be able to live with their parents. like normal children.. measured intelligence. With training.Ovid: Blueprints Psychiatry MANAGEMENT Management depends on the degree of retardation.rs%20of%20Childhood%20and%20Adolescence. arithmetic) substantially below the expectation of a child's chronologic age. The long-term goal of treatment is typically to enable the child to live and function in a supervised group home. mathematics disorder. These forms of mental retardation are often associated with specific syndromes (e. Children with severe or profound mental retardation almost invariably require care in institutional settings.g. to recognize his or her name and a few simple words. Growth and development occur in children with mental retardation.. the course. The child can usually learn to read. The DSM-IV identifies three learning disorders: reading disorder. the child is typically considered educable. reading.htm (8 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . handling small change) without assistance. file:///C|/Documents%20and%20Settings/ASUS/. and disorder of written expression.g. and perform simple arithmetic. and the particular abilities of the child and the parents.. write. usually beginning very early in life. With family support and special education. learning to recognize letters and numbers) in a pattern similar to normal children but at a slower rate. writing. walking. In mild mental retardation. and age-appropriate education. the child is typically considered trainable. Most children with mental retardation progress through normal milestones (standing. that could not have been predicted at an earlier age. They can have developmental spurts. the child can learn to talk. talking. In moderate mental retardation.. and to perform activities of daily living (bathing. dressing. The long-term goal of treatment is to teach the child to function in the community and to hold some type of job. LEARNING DISORDERS Learning disorders are characterized by performance in a specific area of learning (e. Tay-Sachs's disease) in which there is progressive physical deterioration leading to premature death.

Differential Diagnosis It is important to establish that a low achievement score is not caused by some other factor such as lack of opportunity to learn. it is important to consider and test for more global disorders such as pervasive developmental disorder. Finally. Mental Status Examination..Ovid: Blueprints Psychiatry ETIOLOGY Specific learning disorders often occur in families. A specific file:///C|/Documents%20and%20Settings/ASUS/. Because reading and arithmetic are usually not taught before the first grade. and mathematics disorder is estimated at 1%.g. Learning disorders are two to four times more common in boys than girls. They are presumed to result from focal cerebral injury or from a neurodevelopmental defect. CLINICAL MANIFESTATIONS History. Children with learning disorders do not obtain achievement test scores consistent with their overall IQs. It is not uncommon to find that several of these disorders coexist. and Laboratory Tests Specific learning disorders are typically diagnosed after a child has exhibited difficulties in a specific academic area. or cultural factors (e. the diagnosis is seldom made in preschoolers.htm (9 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . EPIDEMIOLOGY Learning disorders are relatively common.rs%20of%20Childhood%20and%20Adolescence. Reading disorder affects 4% of school-age children. Physical factors (such as hearing or vision impairment) must also be ruled out. particularly if they have a high IQ and can mask their deficits... and communication disorders. English as a second language). The incidence of disorder of written expression is not yet known. poor teaching. mental retardation. The diagnosis of learning disorder is confirmed through specific intelligence and achievement testing. Some children may not be diagnosed until fourth or fifth grade.

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learning disorder diagnosis is made when the full clinical picture is not adequately explained by other comorbid conditions.

MANAGEMENT
Children with these disorders often need remedial education, especially if their diagnosis was made late. They also need to be taught learning strategies to overcome their particular deficits. Acceptable skills in the disordered area can often be achieved with steady supportive educational assistance, although P.50

patients may be affected by these disorders throughout adulthood.

PERVASIVE DEVELOPMENTAL DISORDERS
The DSM-IV groups autistic disorder, Rett's disorder, childhood disintegrative disorder, and Asperger's disorder under the heading of pervasive developmental disorders. These conditions are also referred to as autism spectrum disorders because of overlapping aspects of their clinical manifestations.

AUTISTIC DISORDER
Autistic disorder is a common pervasive developmental disorder of childhood onset. It is characterized by the triad of impaired social interactions, impaired ability to communicate, and restricted repertoire of activities and interests.

ETIOLOGY
Autistic disorder is familial. Genetic studies demonstrate incomplete penetrance (36% concordance rate in monozygotic twins), although a specific genetic defect has not been discovered. A small percentage of those with autistic disorder have a fragile X chromosome, and a high rate of autism exists with tuberous sclerosis.

EPIDEMIOLOGY
Autistic disorder is rare. It occurs in two to five children per 10,000 live births. The male:female ratio is 3:1 to 4:1.

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CLINICAL MANIFESTATIONS History, Mental Status Examination, and Laboratory Tests
Abnormal development is usually first noted soon after birth. Commonly, the first sign is impairment in social interactions (failure to develop a social smile, facial expressions, or eye-to-eye gaze). Older children often fail to develop nonverbal forms of communication (e.g., body postures and gestures) and may seem to have no desire or to lack the skills to form friendships. There is also a lack of seeking to share enjoyment (i.e., not showing, sharing, or pointing out objects they find interesting). By definition, findings must be present before age 3.

Autistic disorder is also characterized by a marked impairment in communication. There may be delay in or total lack of language development. Those children who do develop language show impairment in the ability to initiate and sustain conversations and use repetitive or idiosyncratic language. Language may also be abnormal in pitch, intonation, rate, rhythm, or stress.

Finally, there are usually restrictive, repetitive, or stereotyped patterns of behavior, interests, or activities. There may be an encompassing preoccupation with one or more stereotyped and restricted patterns of interest (e.g., amassing baseball trivia), an inflexible adherence to specific nonfunctional routines or rituals (e.g., eating the same meal in the same place at the same time each day), stereotyped or repetitive motor mannerisms (e.g., whole-body rocking), and a persistent preoccupation with the parts of objects (e.g., buttons).

Approximately 25% of children with autistic disorder have comorbid seizures; approximately 75% have mental retardation (the moderate type is most common). EEGs and intelligence testing are typically part of the initial evaluation. Rarely, specific special skills are present (e.g., calendar calculation).

Differential Diagnosis
The diagnosis is usually clear after careful history, mental status examination, and developmental monitoring. Childhood

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psychosis, mental retardation (alone), language disorders, and congenital deafness or blindness, however, must all be ruled out.

MANAGEMENT
Autistic disorder is a chronic lifelong disorder with relatively severe morbidity. Very few individuals with autism will ever live independently. Once the diagnosis is made, parents should be informed that their child has a neurodevelopmental disorder (not a behavioral disorder that they might feel responsible for creating). The parents will have to learn behavioral management techniques designed to reduce the rigid and stereotyped behaviors of the disorder and improve social functioning. Many children with autism require special education or specialized day programs for behavior management.

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Children with autism with a comorbid seizure disorder are treated with anticonvulsants. Low doses of neuroleptics (e.g., haloperidol) and some mood stabilizers and antidepressants have been shown to help decrease aggressive or self-harming behaviors.

RETT'S DISORDER
Rett's disorder is a pervasive developmental disorder that is a major cause of mental retardation in girls.

ETIOLOGY
The precise etiology of Rett's disorder is not known for all cases, but the condition has been most commonly linked to mutations in the gene encoding methyl-CpG-binding protein 2. Neuropathologically, Rett's disorder is associated with microcephaly with increased neuronal density but a decrease in neuronal dendrites and synaptic density in some brain regions.

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EPIDEMIOLOGY
Rett's disorder occurs almost exclusively in females. The condition occurs in about one in every 15,000 births.

CLINICAL MANIFESTATIONS History, Mental Status Examination, and Laboratory Tests
Children with Rett's syndrome appear normal for several months after birth and then develop specific problems. The precise DSM-IV diagnostic criteria require normal head circumference at birth, normal prenatal and perinatal development, and normal psychomotor development through the first 5 months after birth. Following this period of normalcy, there is a decrease in the rate of head growth between months 5 and 48; loss of acquired hand skills between 5 and 30 months (with the onset of stereotyped hand wringing/hand washing-like movements); loss of social engagement early in the illness (that may improve later); poorly coordinated gait or trunk movements; and severe impairments in language development with severe psychomotor retardation. Comorbid severe mental retardation and seizure disorder are common (but mental retardation and seizure are not part of the DSM-IV diagnostic criteria).

There are no laboratory tests for the diagnosis of Rett's disorder, although genotyping may reveal associated mutations. Other genetic conditions must be ruled out.

Differential Diagnosis
The differential diagnostic conditions primarily include other pervasive developmental disorders such as autistic disorder, childhood disintegrative disorder, and Asperger's disorder.

MANAGEMENT
Management is largely via behavioral techniques and treatment of complications. Antiseizure medications, antipsychotic medications, and other psychotropic medications may play a role in managing behavioral difficulties.

CHILDHOOD DISINTEGRATIVE DISORDER
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Childhood disintegrative disorder is characterized by a period of normal development followed by loss of function in multiple domains. It is the most rare of the pervasive developmental disorders.

ETIOLOGY
The etiology of childhood disintegrative disorder is unknown. The condition can be associated with general medical conditions affecting the brain.

EPIDEMIOLOGY
The condition is quite rare and much less common than autism. There may be a preponderance of males.

CLINICAL MANIFESTATIONS History, Mental Status Examination, and Laboratory Tests
The DSM-IV diagnostic criteria for childhood disintegrative disorder require apparently normal childhood development for the first 2 years of life followed by a loss of previously acquired skills before age 10. Previously acquired skills can be lost in the domains of language, social skills and adaptive P.52

behavior, bowel or bladder control, as well as play and motor skills. Additionally, there may be impaired functioning in social interaction or communication, or the development of restricted or repetitive behaviors, interests, and activities. The course is usually chronic once loss of skills has stabilized. This condition usually co-occurs with mental retardation and increased rates of seizure disorder. Laboratory tests are aimed primarily at the exclusion of potentially treatable conditions affecting brain function.

Differential Diagnosis
The differential diagnostic conditions primarily include other pervasive developmental disorders such as autistic disorder,

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Rett's disorder, and Asperger's disorder. Treatable medical conditions affecting brain function should be ruled out.

MANAGEMENT
There is no cure. Management consists primarily of treatment for behavioral difficulties and associated conditions (e.g., seizure disorder).

ASPERGER'S DISORDER
Asperger's disorder may be the most common pervasive developmental disorder (but prevalence figures are controversial) and is characterized by impaired social interactions and restrictive, repetitive, and stereotyped behaviors and interest.

ETIOLOGY
The etiology of Asperger's disorder remains unknown. There is some familial contribution, and numerous genetic, metabolic, and infectious factors have been considered.

EPIDEMIOLOGY
The incidence of Asperger's disorder varies with diagnostic method but is estimated as four per 1,000 children and is approximately four times more common in males. Half of all children with Asperger's disorder may not be diagnosed with the condition.

CLINICAL MANIFESTATIONS History, Mental Status Examination, and Laboratory Tests
The DSM-IV diagnostic features of Asperger's disorder include impairments in social interaction (consisting of severe deficits in multiple nonverbal communication behaviors such as eye-to-eye gaze, facial expression, and body language) and peer relationships, decreased sharing of personal experiences with others, and decreased reciprocal social/emotional interaction. Additionally, there are repetitive and stereotyped behaviors and interests, such as preoccupation with
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stereotyped restricted patterns of interest; a rigid adherence to routines or rituals having little functional use; motor mannerisms and stereotypies; as well as a focus or preoccupation on parts of objects. In Asperger's disorder, there are no delays in language or cognitive, self-help, environmental curiosity, or adaptive behavior domains. The course is usually chronic.

Differential Diagnosis
The differential diagnostic conditions primarily include other pervasive developmental disorders such as autistic disorder, Rett's disorder, and childhood disintegrative disorder.

MANAGEMENT
Treatment for Asperger's disorder is nonspecific and consists of educational, behavioral, and psychotherapeutic approaches targeted at maximizing social interactions. Pharmacologic treatment may be indicated for specific behaviors or comorbid conditions.

ADHD
ADHD is characterized by a persistent and dysfunctional pattern of overactivity, impulsiveness, inattention, and distractibility.

ETIOLOGY
The disorder runs in families and cosegregates with mood disorders, substance use disorders, learning disorders, and antisocial personality disorder. Families P.53

with a child diagnosed with ADHD are more likely than those without ADHD offspring to have family members with the previously mentioned disorders.

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The etiology of the disorder is unknown, but perinatal injury, malnutrition, and substance exposure have all been implicated. Many children with ADHD have abnormalities of sleep architecture (decreased rapid eye movement latency, increased delta latency), EEG, and soft neurologic signs. Brain imaging studies indicate that overall brain volume is smaller in children diagnosed with ADHD when compared with controls.

EPIDEMIOLOGY
The prevalence of ADHD in school-age children is estimated to be 3% to 5%. The boy:girl ratio ranges from 4:1 in the general population to 9:1 in clinical settings. Boys are much more likely than girls to be brought to medical attention.

CLINICAL MANIFESTATIONS History, Mental Status Examination, and Laboratory Tests
To meet criteria for ADHD, a child must evidence the onset of inattentive or hyperactive symptoms before age 7; symptoms must also be present in two or more settings (e.g., school, home). Symptoms in only one setting suggest an environmental or psychodynamic cause.

Preschool-age children are usually brought for evaluation when they are unmanageable at home. Typically, they stay up late, wake up early, and spend most of their waking hours in various hyperactive and impulsive activities. Children with a great deal of hyperactivity may literally run about the house, cause damage, and wreak havoc.

When these children enter school, their difficulties with attention become more obvious. They appear not to follow directions, forget important school supplies, fail to complete homework or in-class assignments, and attempt to blurt out answers to teachers' questions before being called on. Because of their inattention and hyperactivity, these children often become known as “troublemakers.” They fall behind their peers academically and socially.

Evaluation of the child involves gathering a careful history from parents and teachers (the latter usually through report cards and written reports). The child's behavior with and without the parent is carefully observed during psychiatric

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Children with bipolar disorder. write the letters of the alphabet. etc. Symptoms that resemble ADHD can occur in children before age 7. MANAGEMENT file:///C|/Documents%20and%20Settings/ASUS/. Children with oppositional defiant disorder may resist work or school tasks because of an unwillingness to comply with others' demands but not out of difficulty in attention. anxiety disorder) can exhibit inattention but typically not before age 7.htm (18 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . Of course. ADHD must also be differentiated from bipolar disorder. major depressive disorder.g..). Informal testing is carried out by having the child attempt to complete a simple puzzle. and recognize letters traced on the palms (graphesthesia).g. disruptive behavior. Children with other mental disorders (e. A dual diagnosis is made only when it is needed to explain the full clinical picture. Children can also appear inattentive if they have a low or a high IQ and the environment is overstimulating or understimulating.. IQ testing and careful evaluation of the school program will clarify the diagnosis. In either instance. ADHD may be comorbid with any of the previously mentioned disorders. but the etiology is typically a side effect of a medication (e. distinguish right from left. particularly focusing on neurologic function. No specific laboratory or cognitive tests are helpful in making the diagnosis. in addition to distractibility and poor attention.Ovid: Blueprints Psychiatry assessment. Differential Diagnosis It is important to distinguish symptoms of ADHD from age-appropriate behaviors in active children (running about. is imperative.rs%20of%20Childhood%20and%20Adolescence... bronchodilators) or a psychotic or pervasive developmental disorder. these children are not considered to have ADHD. being noisy. The child's history of school adjustment is not usually characterized by teacher or parent reports of inattentive. will exhibit inappropriately intense positive or negative moods. Physical examination. respectively.

It is the most common disorder seen in outpatient psychiatric clinics and is frequently seen comorbidly with ADHD or learning disorders. but psychosocial factors play a major role.54 with ADHD respond favorably to psychostimulants. The long-term outcome depends on the severity of the disorder and the degree and type of comorbidity. parental substance abuse. or serious violations of rules (school truancy.Ovid: Blueprints Psychiatry The management of ADHD involves a combination of somatic and behavioral treatments. Behavioral management techniques include positive reinforcement. and techniques for reducing stimulation (e. focused tasks). 25% to 40% go on to have adult antisocial personality disorder. Parents who retain custody of a child with conduct disorder are taught limit setting.... Most children P.htm (19 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . Some children can be treated effectively with agents that raise norepinephrine in the brain. and association with a delinquent peer group have been shown to have some relationship to the development of conduct disorder. Medications are used only to treat a comorbid ADHD or mood disorder but not for the conduct disorder itself. theft. deceitfulness. firm limit setting. running away). consistency. Of children with conduct disorder. Parental separation or divorce. the school day) because psychostimulants have undesirable long-term physical effects (weight loss and inhibited body growth). Methylphenidate is the first-line agent.e. one playmate at a time. such as bupropion (Wellbutrin) or atomoxetine (Strattera). Clinicians try to use the smallest effective dose and to restrict use to periods of greatest need (i. Adoption studies show a genetic predisposition. Some children may need to be removed from the home and placed in foster care. short. severely poor or inconsistent parenting. Treatment involves individual and family therapy.. file:///C|/Documents%20and%20Settings/ASUS/. CONDUCT DISORDER AND OPPOSITIONAL DEFIANT DISORDER Conduct disorder is defined as a repetitive and persistent pattern of behavior in which the basic rights of others or important age-appropriate societal norms or rules are violated. and other behavioral techniques.rs%20of%20Childhood%20and%20Adolescence. a norepinephrine reuptake inhibitor.g. Disordered behaviors include aggression toward people or animals. destruction of property. followed by D-amphetamine. Conduct disorder is the childhood equivalent of adult antisocial personality disorder.

Motor tics can involve facial grimacing. Mental Status and Physical Examinations The patient or family usually describes an onset in childhood or early adolescence before age 18.. but being overwhelmed by an uncontrollable urge to say them. CLINICAL MANIFESTATIONS History. difficult. The patient describes being aware of shouting the words. tongue protrusion. snorting. Motor tics typically antedate vocal tics. There is a 3:1 male:female ratio. TOURETTE'S DISORDER Tourette's disorder is a rare disorder in which the child demonstrates multiple involuntary motor and vocal tics. the words are sometimes obscenities (coprolalia). no gene (or genes) has yet been discovered to explain the etiology of the disorder. rapid. nonrhythmic. Management emphasizes individual and family counseling. being able to exert some control over them. barks or grunts typically antedate file:///C|/Documents%20and%20Settings/ASUS/. or disruptive behavior when the frequency of the behavior significantly exceeds that of other children his or her mental age (or that is less tolerated in the child's particular culture). EPIDEMIOLOGY Tourette's disorder affects 0. ETIOLOGY Tourette's disorder is highly familial and appears to frequently co-occur with obsessive-compulsive disorder.4% of the population. Despite evidence of genetic transmission in some families. Vocal tics are usually loud grunts or barks but can involve shouting words.rs%20of%20Childhood%20and%20Adolescence. recurrent.Ovid: Blueprints Psychiatry Oppositional defiant disorder is diagnosed in a child with annoying. or larger movements of the extremities or whole body. blinking. It is a relatively new diagnosis that is meant to describe children with behavior problems that do not meet criteria for full-blown conduct disorder. A tic is a sudden.. stereotyped motor movement or vocalization.htm (20 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ .

. but various other agents are used. The motor tics are not painful. gastrointestinal complications.55 Differential Diagnosis A careful neurologic evaluation should be performed to rule out other causes of tics.g. P. embarrassment. MANAGEMENT Treatment for more severe tics typically involves the use of low doses of high-potency neuroleptics such as haloperidol or pimozide. Wilson's disease and Huntington's disease are the principal differential diagnostic disorders.htm (21 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . Little is known about the etiology and epidemiology of pica.. The child and his or her family should receive education and supportive psychotherapy aimed at minimizing the negative social consequences (e. Stimulants used to treat other psychiatric disorders may unmask tics. An EEG should be performed to rule out a seizure disorder. Medical complications such as lead poisoning. isolation) that occur with this disorder.rs%20of%20Childhood%20and%20Adolescence. rates of pica increase with increasing severity of mental retardation. In the mentally retarded. shame. Careful evaluation for other comorbid psychiatric illnesses should be performed. and infectious consequences may result. The disorder may be sustained or self-limited. CHILDHOOD FEEDING AND EATING DISORDERS PICA Pica is a condition characterized by the developmentally inappropriate ingestion of nonnutritive substances for a period of at least 1 month.Ovid: Blueprints Psychiatry verbal shouts.. RUMINATION DISORDER file:///C|/Documents%20and%20Settings/ASUS/. when the ingestion of nonnutritive substances is not part of a culturally sanctioned behavior.

Associated conditions such as those resulting from malnutrition with impaired sleep. The inappropriate defecation cannot be caused by another medical condition or drug with the exception of constipation. FEEDING DISORDER OF INFANCY OR EARLY CHILDHOOD Feeding disorder is characterized by continued failure to eat enough food. The regurgitative behavior cannot be caused by gastrointestinal difficulties or another eating disorder such as bulimia nervosa. but it may appear at a later age in mentally retarded individuals. encopresis is classified according to whether or not there is constipation with overflow incontinence. The etiology is unknown.rs%20of%20Childhood%20and%20Adolescence. Regurgitated food may be expelled or rechewed and swallowed.htm (22 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . If regurgitation is severe and insufficient calories are ingested. ENURESIS The diagnostic criteria for enuresis require repeated episodes (two times per week for at least 3 consecutive months or the presence of significant distress) of urination into one's clothes or bed in children at least 5 years old or having an file:///C|/Documents%20and%20Settings/ASUS/. and developmental delays may occur. Spontaneous remission is common. ELIMINATION DISORDERS ENCOPRESIS The diagnostic criteria for encopresis require repeated episodes (at least once per month for at least 3 months) of defecation in inappropriate places in individuals at least 4 years old or having an equivalent developmental level. The etiology is unclear but impaired caregiver-child interactions may play a role. leading to weight loss or failure to gain weight and lasting at least 1 month. About 1% of 5-year-olds display encopresis... When present. irritability. The condition appears rare and is most commonly diagnosed in infants. malnutrition can occur. Mortality rates may approach 25%. The condition cannot be a result of a general medical condition.Ovid: Blueprints Psychiatry Rumination disorder is a feeding disorder characterized by repeated regurgitation of ingested food for at least 1 month after a period of normal eating.

● Learning disorders tend to be familial and probably result from cerebral injury or maldevelopment. ● Reading disorder is the most common learning disorder.rs%20of%20Childhood%20and%20Adolescence. reading.56 KEY POINTS ● Mental retardation is defined by IQ less than or equal to 70 and impaired functioning in specific areas. P.. is most commonly caused by Down's syndrome (trisomy 21). Enuresis is classified according to the time of day of occurrence as nocturnal only. and written expression. diurnal only. ● There are three types of learning disorders: mathematics. ● file:///C|/Documents%20and%20Settings/ASUS/. which is more common in males (2:1). ● Mental retardation.. or nocturnal and diurnal. About 7% of 5-year-old boys have enuresis.htm (23 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . and all three disorders occur more often in boys (2:1 to 4:1). The prevalence is about 3% in 5-year-old girls.Ovid: Blueprints Psychiatry equivalent developmental level. The inappropriate urination cannot be a result of a general medical condition or substance.

. ● Asperger's disorder is likely the most common pervasive developmental disorder.rs%20of%20Childhood%20and%20Adolescence. ● Conduct disorder is the childhood equivalent of adult antisocial personality disorder and is the most common diagnosis in outpatient child psychiatric clinics. Rett's disorder.htm (24 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . ● Oppositional defiant disorder is a less severe form of conduct disorder. other causes of inattentiveness or hyperactivity must be ruled out. ● There are three types of feeding and eating disorders of infancy or early childhood: pica (developmentally inappropriate eating of nonnutritive substances). most cases are associated with alterations in methyl-CpG-binding protein 2.. ● Language is preserved in Asperger's disorder but not in autistic disorder. and Asperger's disorder. ● ADHD is more common in boys (4:1) and is characterized by inattentiveness and hyperactivity occurring in multiple settings. rumination disorder file:///C|/Documents%20and%20Settings/ASUS/. childhood disintegrative disorder. ● For a diagnosis of ADHD.Ovid: Blueprints Psychiatry There are four types of pervasive developmental disorders (also referred to as autism spectrum disorders): autistic disorder. ● Rett's disorder occurs almost exclusively in females. and symptoms must begin before age 7.

. file:///C|/Documents%20and%20Settings/ASUS/.rs%20of%20Childhood%20and%20Adolescence.Ovid: Blueprints Psychiatry (repeated regurgitation of ingested food). and feeding disorder (failure to eat enough to maintain or gain weight in the absence of other medical causes).htm (25 of 25) [30/01/2009 06:21:51 ‫]ﻡ‬ . ● There are two types of elimination disorders: encopresis (repeated episodes of inappropriate defecating) and enuresis (repeated episodes of inappropriate urination)..

5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 8 ./Chapter%208%20-%20Cognitive%20Disorders. mild anemia. Ronald L. and amnestic disorders.. Common medical causes of delirium include metabolic file:///C|/Documents%20and%20Settings/ASUS/M. Table 8-1 lists the Diagnostic and Statistical Manual of Mental Disorders. delirium is the result of a general medical condition.Cognitive Disorders Chapter 8 Cognitive Disorders The cognitive disorders are delirium.. ETIOLOGY Delirium is a syndrome with many causes but ultimately results from global cerebral cortical dysfunction. or as multifactorial in origin. Michael J. as substance-related. Structural central nervous system lesions can also lead to delirium. however. DELIRIUM Delirium is a reversible state of global cerebral cortical dysfunction characterized by alterations in attention and cognition and produced by a definable precipitant. alterations in other neurotransmitters such as γ-aminobutyric acid and dopamine are also implicated. dementia. Delirium is categorized by its etiology (Table 8-1) as caused by general medical conditions. substance intoxication and withdrawal are also common causes. Cowan. Delirium is often multifactorial and may be produced by a combination of minor illnesses and minor metabolic derangements (e. The neurotransmitter most commonly implicated in delirium is acetylcholine.Ovid: Blueprints Psychiatry Authors: Murphy.htm (1 of 12) [30/01/2009 06:21:57 ‫]ﻡ‬ . and urinary tract infection. mild hypoxia. classification of cognitive disorders. 4th edition.. mild hyponatremia. especially in an elderly person). Title: Blueprints Psychiatry.. Decreased central nervous system acetylcholine is thought to cause delirium. Most frequently.g. Table 8-2 lists common general medical and substance-related causes of delirium.

Other conditions predisposing to delirium include old age.. prior trauma. hypercapnia. whether associated with overt dementia. The common substance-induced causes of delirium are alcohol or benzodiazepine withdrawal and benzodiazepine and anticholinergic drug toxicity. and pre-existing dementia.58 development of the delirium and to the prior existence of dementia or other psychiatric illness. hypoglycemia.Ovid: Blueprints Psychiatry abnormalities such as hyponatremia. hypoxia. fractures. both prescribed and available over the counter. pneumonia. can produce delirium. particularly in regard to the time course of P. Delirium is equally common in men and women.htm (2 of 12) [30/01/2009 06:21:57 ‫]ﻡ‬ . especially urinary tract infections. and hypercalcemia. Brain damage of any kind. although a great number of commonly used medications. Delirium occurs in 10% to 15% of general medical patients older than age 65 and is frequently seen postsurgically and in intensive care units. are often implicated. EPIDEMIOLOGY The exact prevalence of delirium in the general population is unknown.. and meningitis. or ischemic changes./Chapter%208%20-%20Cognitive%20Disorders. Infectious illnesses. is a risk factor for the development of delirium. CLINICAL MANIFESTATIONS History and Mental Status Examination The clinical history is critical in the diagnosis of delirium. Key features of delirium are as follows: ▪ TABLE 8-1 Cognitive Disorders Delirium General medical Substance-related Multifactorial Dementia Alzheimer's type Vascular origin Head trauma-related Lewy body-related Huntington's-related Amnestic General medical Substance-related file:///C|/Documents%20and%20Settings/ASUS/M.

and ● Presence of medical or substance-related precipitants. language..Ovid: Blueprints Psychiatry Frontotemporal degeneration Creutzfeldt-Jakob-related General medical origin Substance-related Multifactorial ● Disturbance of consciousness. orientation. ● Alterations in cognition. especially attention and level of arousal. ● Development over a period of hours to days. and perception.. ▪ TABLE 8-2 Common Causes of Delirium file:///C|/Documents%20and%20Settings/ASUS/M./Chapter%208%20-%20Cognitive%20Disorders. especially memory.htm (3 of 12) [30/01/2009 06:21:57 ‫]ﻡ‬ .

the deficits are generally more stable. there may be nocturnal worsening of symptoms with increased agitation and confusion (“sundowning”). Key differentiating factors are the time course of development of the mental status change (especially if the patient did not have a prior dementia) and the presence of a likely precipitant for the mental status change. as outlined in Table 8-3.. whereas in dementia. file:///C|/Documents%20and%20Settings/ASUS/M.Ovid: Blueprints Psychiatry In addition. in part because dementia is a risk factor for delirium (and thus.. In both conditions. sleep-wake cycle disturbances and psychomotor agitation may occur.htm (4 of 12) [30/01/2009 06:21:57 ‫]ﻡ‬ . Individuals with delirium may also display periods of complete lucidity interspersed with periods of confusion./Chapter%208%20-%20Cognitive%20Disorders. Delirium is often difficult to distinguish from dementia. The available evidence suggests that there are subtypes of delirium identifiable via clinical observation of psychomotor activity. they frequently co-occur) and also in part because there is a great deal of symptom overlap.

orientation. orientation. language. and laboratory tests targeted at identifying general medical and substance-related causes. or progressive over weeks to years Attention Cognition Impaired Impaired memory. The diagnosis of delirium is complicated by the fact that there are no definitive tests for delirium. An assessment for possible delirium in a quiet. may be permanent. arterial blood gas assessment. neuroimaging. and mixed deliria. may last hours to weeksa Weeks to years Stable within a day. The presence of a delirium is associated with a 1-year mortality rate of 40% to 50%. reversible. ▪ TABLE 8-3 Delirium Versus Dementia Delirium Onset Course/duration Hours to days Fluctuates within a day. may be critical in the overall medical treatment of such a patient. executive function Perception Sleep/wake Mood/emotion Sundowning Identified precipitant Hallucinations. delusions Disturbed. or electroencephalogram. and oxygen saturation.59 complete blood count. language May be impaired Impaired memory. may have complete day/night reversal Labile affect Frequent Likely precipitant is present Hallucinations. Additional workup might entail chest radiographs.Ovid: Blueprints Psychiatry These can be characterized as hypoactive.htm (5 of 12) [30/01/2009 06:21:57 ‫]ﻡ‬ ./Chapter%208%20-%20Cognitive%20Disorders. may have no pattern Labile affect. An electroencephalogram may reveal nonspecific diffuse slowing. hyperactive. delusions. misinterpretations Disturbed. however. Further research is needed to validate these subtypes and develop subtype-specific treatment strategies. P. complete chemistry panel. a physical examination. The workup for delirium includes a thorough history and mental status examination. mood disturbances Frequent Identifiable precipitant not required Dementia file:///C|/Documents%20and%20Settings/ASUS/M. or hypoactive patient... These should include urinalysis.

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a

The DSM-IV does not specify a limit for the duration for delirium; clinical experience suggests resolution within days to weeks, in

most cases.

Differential Diagnosis
Delirium should be differentiated from dementia (although both can be present at the same time), psychotic or manic disorganization, and status complex partial epilepsy.

MANAGEMENT
The treatment of delirium involves keeping the patient safe from harm while addressing the delirium. In the case of delirium resulting from a general medical illness, the underlying illness must be treated; in substance-related delirium, treatment involves removing the offending drug (either drugs of abuse or medications) or the appropriate replacement and tapering of a cross-reacting drug to minimize withdrawal. Delirium in elderly individuals is frequently multifactorial and requires correction of a multitude of medical conditions. The essential element in the treatment of delirium is to address all of the contributing medical issues.

In addition to addressing the cause of a delirium as the mainstay of treatment, oral, intramuscular, or intravenous haloperidol is of great use in treating delirium-associated agitation. Atypical antipsychotic medications are also used; however, there are no treatments for delirium approved by the United States Food and Drug Administration. Although alcohol or benzodiazepine withdrawal delirium is treated in part with benzodiazepines, benzodiazepines may worsen or precipitate delirium arising from other causes. Providing the patient with a brightly lighted room with orienting cues such as names, clocks, and calendars is also useful.

DEMENTIA
Dementia is characterized by the presence of memory impairment in the presence of other cognitive defects. Dementia is categorized according to its etiology (Table 8-1). It can arise as a result of a specific P.60

disease, for example, Alzheimer's disease or human immunodeficiency virus infection; a general medical condition; a
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substance-related condition; or it can have multiple etiologies. The definitive cause may not be determined until autopsy.

ETIOLOGY
Generally, the etiology of dementia is brain neuronal loss that may be caused by neuronal degeneration or cell death secondary to trauma, infarction, hypoxia, infection, or hydrocephalus. Table 8-1 lists the major discrete illnesses known to produce dementia. In addition, there are a large number of general medical, substance-related, and multifactorial causes of dementia.

EPIDEMIOLOGY
The prevalence of dementia of all types is about 2% to 4% after age 65, increasing with age to a prevalence of about 20% after age 85. Specific epidemiologic factors relating to disease-specific causes of dementia are listed in Table 8-4.

CLINICAL MANIFESTATIONS History and Mental Status Examination
Dementia is diagnosed in the presence of multiple cognitive defects not better explained by another diagnosis. The presence of memory loss is required; in addition, one or more cognitive defects in the categories of aphasia, apraxia, agnosia, and disturbance in executive function must be present. Table 8-3 compares characteristics of dementia with those of delirium. Dementia often develops insidiously over the course of weeks to years (although it may be abrupt after head trauma or vascular insult). Individuals with dementia usually have a stable presentation over brief periods of time, although they may also have nocturnal worsening of symptoms (“sundowning”). Memory impairment is often greatest for short-term memory. Recall of names is frequently impaired, as is recognition of familiar objects. Executive functions of organization and planning may be lost. Paranoia, hallucinations, and delusions are often present. Eventually, individuals with dementia may become mute, incontinent, and bedridden.

Differential Diagnosis
Dementia should be differentiated from delirium. In addition, dementia should be differentiated from those developmental disorders (such as mental retardation) with impaired cognition. Individuals with major depression and psychosis can appear to suffer dementia; they warrant a diagnosis of dementia only if their cognitive deficits cannot be fully attributed to the primary
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psychiatric illness.

A critical component of differential diagnosis in dementia is to distinguish pseudodementia associated with depression. Although there are many precise criteria for separating the two disorders, neuropsychological testing may be needed to make an accurate diagnosis. In pseudodementia, mood symptoms are prominent, and patients may complain extensively of memory impairment. They characteristically give “I don't know” answers to mental status examination queries but may answer correctly if pressed. Memory is intact with rehearsal in pseudodementia but not in dementia.

MANAGEMENT
Dementia from reversible, or treatable, causes should be managed first by treating the underlying cause of the dementia; rehabilitation may be required for residual deficits. Reversible (or partially reversible) causes of dementia include normal pressure hydrocephalus; neurosyphilis; human immunodeficiency virus infection; and thiamine, folate, vitamin B12, and niacin deficiencies. Vascular dementias may not be reversible, but their progress can be halted in some cases. Nonreversible dementias are usually managed by placing the patient in a safe environment and by medications targeted at associated symptoms. There are four acetylcholinesterase inhibitor medications (tacrine, rivastigmine, donepezil, and galantamine) currently approved for the treatment of Alzheimer's dementia. Tacrine has the highest rate of hepatotoxicity. The acetylcholinesterase inhibitors improve cognitive function and global function. High-potency antipsychotics (in low doses) are used when agitation, paranoia, and hallucinations are present. Atypical antipsychotic medications are often used as well but appear to increase the risk of stroke and other forms of mortality in elderly individuals. Although low-dose benzodiazepines and trazodone are often used for anxiety, agitation, or insomnia, both benzodiazepines and trazodone may increase the risk of falls and should be used sparingly.

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▪ TABLE 8-4 Specific Diseases Associated With Dementia

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Disease Alzheimer's

Description Most common cause of dementia. Accounts for greater than 50% of all cases. Risk factors are familial, Down's syndrome, prior head trauma, increasing age. Clinically, it is a diagnosis of exclusion. Postmortem pathology reveals cortical atrophy, neurofibrillary tangles, amyloid plaques, granulovacuolar degeneration, and loss of basal forebrain cholinergic nuclei. Course is progressive. Death occurs 8 to 10 years after onset on average.

Vascular

Risk factors are cardiovascular and cerebrovascular disease. Neuroimaging reveals multiple areas of neuronal damage. Neurological examination reveals focal findings. Course can be rapid onset or more slowly progressive. Deficits are not reversible, but progress can be halted with appropriate treatment of vascular disease.

Human immunodeficiency virus

Limited to cases caused by direct action of human immunodeficiency virus on the brain; associated illnesses, such as meningitis, lymphoma, toxoplasmosis-producing dementia are categorized under dementia caused by general medical conditions. Primarily affects white matter and cortex.

Head trauma

Most common among young males. Extent of dementia is determined by degree of brain damage. Deficits are stable unless there is repeated head trauma.

Lewy body*

Dementia of Parkinson's disease is a type of Lewy body dementia. Occurs in 20% to 60% of individuals with Parkinson's disease. The most likely pathological finding on autopsy is Lewy body disease. Bradyphrenia (slowed thinking) is common. Some individuals also have pathology at autopsy consistent with Alzheimer's dementia.

Huntington's

Risk factors are familial, autosomal dominant on chromosome 4. Onset commonly in mid-30s. Emotional lability is prominent. Caudate atrophy is present on autopsy.

Frontotemporal* degeneration

Pick's disease is a type of frontotemporal degeneration. Onset of Pick's occurs at age 50 to 60. Frontal and temporal atrophy are prominent on neuroimaging. The dementia responds poorly to psychotropic medicine.

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Creutzfeldt-Jakob

Familial in 10% of cases. Onset age is 40 to 60. Prion is thought to be agent of transmission. Clinical triad of dementia, myoclonus, and abnormal electroencephalogram. Rapidly progressive. Spongiform encephalopathy is present at autopsy.

*

The DSM-IV does not classify Lewy body or frontotemporal dementia as primary types of dementias but classifies them as general

medical causes of dementia. But, the DSM-IV does classify Parkinson's-related dementia and Pick's-related dementia as specific types of Lewy body and frontotemporal dementia, respectively.

AMNESTIC DISORDERS
Amnestic disorders are isolated disturbances of memory without impairment of other cognitive functions. They may be result from a general medical condition or may be substance related.

ETIOLOGY
Amnestic disorders are caused by general medical conditions or substance use. Common general medical conditions include head trauma, hypoxia, herpes simplex encephalitis, and posterior cerebral artery infarction. Amnestic disorders often are associated with damage of the mammillary bodies, fornix, and hippocampus. Bilateral damage to these structures produces the most severe deficits. Amnestic disorders resulting from substance-related causes may be the result of substance abuse, use of prescribed or over-the-counter medications, or accidental exposure to toxins. Alcohol abuse is a leading cause of substance-related amnestic disorder. Persistent alcohol use may lead to thiamine deficiency and induce Wernicke-Korsakoff's syndrome (see Chapter 5 for discussion of Wernicke-Korsakoff's syndrome). If properly treated, the acute symptoms of ataxia, abnormal eye movements, and confusion may resolve, leaving a residual P.62

amnestic disorder called alcohol-induced persistent amnestic disorder (Korsakoff psychosis).

EPIDEMIOLOGY
Individuals affected by a general medical condition or alcoholism are at risk for amnestic disorders.

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CLINICAL MANIFESTATIONS History and Mental Status Examination
Amnestic disorders present as deficits in memory, either in the inability to recall previously learned information or the inability to retain new information. The cognitive defect must be limited to memory alone; if additional cognitive defects are present, a diagnosis of dementia or delirium should be considered. In addition to defect in memory, there must be an identifiable cause for the amnestic disorder (i.e., the presence of a general medical condition or substance use).

Differential Diagnosis
Delirium and dementia are the major differential diagnostic considerations. Amnestic disorders are distinguished from dissociative disorders on the basis of etiology. By definition, amnestic disorders result from a general medical condition or substance.

MANAGEMENT
The general medical condition is treated whenever possible to prevent further neurologic damage; in the case of a substance-related amnestic disorder, avoiding re-exposure to the substance responsible for the amnestic disorder is critical. Pharmacotherapy may be directed at treating associated anxiety or mood difficulties. Patients should be placed in a safe, structured environment with frequent memory cues.

KEY POINTS

Delirium is a disorder of attention and cognition likely resulting from alterations in multiple neurotransmitters.

There are hypoactive, hyperactive, and mixed subtypes of delirium.

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Delirium has an identifiable precipitant, an abrupt onset, and a variable course.

The 1-year mortality rate for delirium is greater than 40%.

Dementia is a disorder of memory impairment coupled with other cognitive defects.

Dementia may be caused by a variety of illnesses and has a gradual onset and progressive course.

Dementia predisposes to delirium.

Amnestic disorders are disorders in memory alone.

The disorders are caused by identifiable precipitants.

Amnestic disorders are reversible in some cases.

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Authors: Murphy, Michael J.; Cowan, Ronald L. Title: Blueprints Psychiatry, 5th Edition

Copyright ©2009 Lippincott Williams & Wilkins

> Table of Contents > Chapter 9 - Miscellaneous Disorders

Chapter 9 Miscellaneous Disorders

Miscellaneous disorders do not refer to any official Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) classification but rather to psychiatric diagnoses not covered elsewhere in this book. Generally, these diagnoses are either less common, less understood, or less frequently the focus of psychiatric practice than the disorders previously covered. Although many of these disorders are not uncommon, they seldom come to psychiatric attention for a variety of reasons (e.g., they may be treated by other medical specialists, patients may not mention them, or they may not be detected adequately). Table 9-1 lists the categories of disorders discussed in this chapter.

DISSOCIATIVE DISORDERS
Dissociative disorders are characterized by disturbances in the integration of mental functions. These disturbances are manifested by loss of memory for personal information or identity, division of consciousness and personality into separate parts, and altered perception of the environment or sense of reality. Table 9-2 lists DSM-IV defined dissociative disorders.

DISSOCIATIVE AMNESIA
In dissociative amnesia, an individual develops a temporary inability to recall important personal information. The amnesia is more extensive than forgetfulness and is not caused by another medical or psychiatric condition (e.g., head trauma). The inability to recall information may take several forms. In localized amnesia, information is lost for a specific time period (e.g., a time associated with trauma). In selective amnesia, some information during a given time period is retained, but other information is lost. In generalized amnesia, personal information is lost for the entire life span. In continuous amnesia, there is an inability to recall information from a single point in time to the present. In systematized amnesia, particular categories of information are lost to retrieval.

Dissociative amnesia is more common in people exposed to trauma, for example, those exposed to battle or natural disaster.

DISSOCIATIVE FUGUE
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Dissociative fugue is an amnestic disorder characterized by an individual's sudden unexplained travel away from home, coupled with amnesia for his or her identity. In this condition, patients do not appear mentally ill or otherwise impaired in any other mental function, including memory. In fact, patients are quite capable of negotiating the complexities of travel and interaction with others. In rare cases, an individual will establish a completely new identity in the new home. Dissociative fugue is typically precipitated by a severe trauma or stressor and eventually remits without treatment.

DISSOCIATIVE IDENTITY DISORDER
Dissociative identity disorder (formerly called multiple personality disorder) is a controversial diagnosis in psychiatry. The diagnosis of dissociative identity P.64

disorder requires the presence of two or more separate personalities (alters) that recurrently take control of an individual's behavior. Individuals with this disorder often have amnesia for important personal information (also known as losing time). The various personalities (the average number by available surveys is seven distinct personalities) may be unaware of each other's existence and thus may be quite confused as to how they arrived at certain places or why they cannot recall personal events. At other times, one or more personalities may be aware of the others, a condition known as co-consciousness. Some personalities may display conversion symptoms or self-mutilating behavior. The alters may be of varying ages and different genders and demeanors.

▪ TABLE 9-1 Miscellaneous Disorders
Dissociative disorders Somatoform disorders Adjustment disorders Sexual and gender identity disorders Sleep disorders Factitious disorders/malingering

Dissociative identity disorder is most common in females and has a chronic course. Individuals with dissociative identity disorder are highly suggestible and easily hypnotized. Most report a childhood history of severe physical or sexual abuse. Satanic or cult abuse reports are also common. In some cases, these reports of abuse cannot be verified, leading many clinicians to believe that individuals with dissociative identity disorder may suffer from memories of events that did not occur. Whether these memories are true or false,
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they cause a great deal of suffering.

▪ TABLE 9-2 Dissociative Disorders
Dissociative amnesia Dissociative fugue Dissociative identity disorder Depersonalization disorder Temporary inability to recall important personal information; more serious than simple forgetfulness Amnesia for one's identity coupled with sudden unexplained travel away from home Presence of two or more separate personalities that recurrently take control of a person's behavior Pervasive sense of being detached from or being outside of one's body

Disagreement over the very nature of dissociative identity disorder has led to divergent treatment opinions.

Some clinicians believe that ignoring the different personalities will cause them to recede, based on the notion that the easy suggestibility of these patients will lead to reinforcement of alters if they are discussed. Others believe that long-term psychotherapy, exploring the various personalities and integrating them into a whole person, is the treatment of choice. Medication treatments are usually targeted at symptom relief or comorbid conditions.

Dissociative identity disorder may be best conceptualized as a trauma spectrum disorder associated with severe trauma exposure. Patients with dissociative identity disorder have very high rates of posttraumatic stress disorder (about 70%) and about 50% of patients with dissociative identity disorder also have somatization disorder. Mood disorders are also present in a majority of patients.

DEPERSONALIZATION DISORDER
Depersonalization disorder is characterized by “persistent or recurrent experiences of feeling detached from and as if one is an outside observer of one's mental processes or body” (DSM-IV). Individuals with this disorder may complain of a sense of detachment, of feeling mechanical or automated, and of absence of affect or sensation. Individuals with depersonalization disorder are easily hypnotized and prone to dissociate.

SOMATOFORM DISORDERS
Somatoform disorders are characterized by the presence of physical signs or symptoms without medical cause. In addition, they are not willfully produced by the individual. Namely, in contradistinction to factitious disorder and malingering, the symptoms of

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somatoform disorders are assumed to be subconscious in origin. The somatoform disorders are listed and defined in Table 9-3.

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▪ TABLE 9-3 Somatoform Disorders
Somatization disorder Chronic multiple medical complaints that include pain, gastrointestinal disturbance, sexual symptoms, and pseudoneurologic symptoms that are not caused by a medical illness Undifferentiated somatoform disorder Conversion disorder A less severe form of somatization disorder; involves fewer complaints and briefer course Complaints involving sensory (such as numbness) and voluntary motor (such as paralysis) function that are not caused by neurologic dysfunction Pain disorder Pain is the major complaint; if medical causes are present, psychological factors have a major role in mediating the expression and impact of pain Hypochondriasis Body dysmorphic disorder Preoccupation with having a serious disease based on a misinterpretation of bodily function and sensation Excessive concern with a perceived defect in appearance

Adapted from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 2000.

SOMATIZATION DISORDER
Somatization disorder is diagnosed when an individual has multiple medical complaints that are not the result of medical illness. The specific DSM-IV criteria are narrow and specific, requiring

Pain in four different body sites or involving four different body functions;

Two gastrointestinal symptoms (other than pain);

One sexual symptom (other than pain); and

One pseudoneurologic symptom (other than pain).

In addition, some symptoms must have begun before age 30 and persisted for several years. Individuals with somatization disorder

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often have a history of complex medical and surgical treatments that may actually lead to iatrogenic complications of treatment. Patients with somatoform disorder frequently have multiple physicians, make frequent office and hospital visits, and may seek disability because of their conviction that they are severely and chronically medically ill.

This disorder is more common in females (approximately 80% of cases), and its incidence is increased in first-degree relatives of those with somatization disorder. Familial and genetic studies have also shown that male relatives of individuals with somatization disorder have an increased incidence of antisocial personality disorder and substance abuse. Adoption studies suggest genetic influences in this disorder.

Various theories have been proposed to explain this disorder. Early psychoanalytic work focused on repressed instincts as causative; more modern theorists propose that somatization symptoms may represent a means of nonverbal interpersonal communication. Biologic findings have revealed abnormal cortical function in some individuals with this disorder. Overall, the disorder appears to be best explained using an integrated biopsychosocial approach grounded in cognitive interpretations and learning theory.

Cognitive-behavioral therapy is the most effective treatment for somatization disorder. Antidepressant medications are also helpful in patients with or without comorbid depressive symptoms. Additional strategies for treating somatization include regular, structured visits by a single physician with the goal of avoiding excessive or invasive diagnostic workups and visits by the patient to other physicians or emergency wards.

ADJUSTMENT DISORDERS
According to DSM-IV, adjustment disorders are symptoms (changes in emotional state or behaviors) that arise in response to an identified psychosocial stressor that is out of proportion to what is expected in usual human experience. Adjustment disorder is not diagnosed if the symptoms occurred in response to a psychosocial stressor so severe that an individual meets criteria for another Axis I disorder (e.g., major depression). Symptoms in response to bereavement do not meet criteria for the diagnosis of adjustment disorder. Adjustment disorders occur within 3 months of the identified stressor and usually resolve within 6 months, unless the stressor becomes chronic.

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▪ TABLE 9-4 Sexual Response Cycle

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Desire Excitement Orgasm Resolution

Initial stage of sexual response; consists of sexual fantasies and the urge to have sex Consists of physiologic arousal and feeling of sexual pleasure Peaking sexual pleasure; usually associated with ejaculation in men Physiologic relaxation associated with sense of well-being; in men, there is usually a refractory period for further excitement and orgasm

SEXUAL AND GENDER IDENTITY DISORDERS
The DSM-IV classifies these disorders into sexual dysfunctions, paraphilia, and gender identity disorders.

SEXUAL DYSFUNCTIONS
Sexual dysfunctions are sexual disorders associated with alterations in the sexual response cycle (Table 9-4) or with pain associated with sexual activity. The specific sexual dysfunctions are defined in Table 9-5.

▪ TABLE 9-5 Specific Sexual Dysfunctions
Sexual desire disorders Hypoactive sexual desire disorder Sexual fantasy and desire for sex very low or absent Sexual aversion disorder Aversion to genital sexual contact with another person Sexual arousal disorders Female sexual arousal disorder Inadequate vaginal lubrication and inadequate engorgement of external genitalia Male erectile disorder Orgasmic disorders Female orgasmic disorder Inability to attain or maintain an erection Orgasm is absent or delayed; sexual excitement phase is normal Male orgasmic disorder Orgasm is absent or delayed; sexual excitement phase is normal Premature ejaculation Orgasm and ejaculation occur early and with minimal stimulation

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Sexual pain disorders

Dyspareunia Vaginismus

Genital pain in association with sexual intercourse Involuntary contraction of external vaginal musculature as a result of attempted penetration

Sexual dysfunction resulting from a general medical condition Substance-induced sexual dysfunction

PARAPHILIAS
Paraphilias include sexual disorders related to culturally unusual sexual activity (Table 9-6). A key criterion for the diagnosis of a paraphilia (as in all psychiatric disorders) is that the disorder must cause an individual to experience significant distress or impairment in social or occupational functioning. In other words, an individual with unusual sexual practices who does not suffer significant distress or impairment would not be diagnosed with a psychiatric illness.

GENDER IDENTITY DISORDER
Gender identity disorder remains a controversial diagnosis in psychiatry. Individuals with this disorder experience distress and interpersonal impairment as a result of their desire to be a member of the opposite sex. Criteria for the diagnosis require a pervasive cross-gender identification and persistent discomfort with one's assigned sex. In addition, the diagnosis is made only in those individuals who do not have an intersex condition (e.g., ambiguous genitalia). Children with this disorder may engage in gender-atypical play; adults may assume the societal role, dress, and behavior associated with the P.67

opposite sex. In addition, patients with gender identity disorder may seek sex reassignment surgery and hormonal supplements. Individuals with gender identity disorder appear to have the same range of sexual orientations as do persons without this disorder.

▪ TABLE 9-6 Paraphilias
Exhibitionism Fetishism Frotteurism Pedophilia Sexual masochism Sexual sadism Sexual excitement is derived from exposing one's genitals to a stranger Nonliving objects are the focus of intense sexual arousal in fantasy or behavior Sexual excitement is derived by rubbing one's genitals against or by sexually touching a nonconsenting stranger Sexual excitement is derived from fantasy or behavior involving sex with prepubescent children Sexual excitement is derived from fantasy or behavior involving being the recipient of humiliation, bondage, or pain Sexual excitement is derived from fantasy or behavior involving inflicting suffering/humiliation on another

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68 histogram and electroencephalographic characteristics of each stage... Depth of sleep is greater than stage 2 but probably less than delta. transition from wakefulness to sleep. Table 9-8 outlines the DSM-IV classification of sleep disorders. cognitive.. EEG. Very deep stage of sleep. Primary sleep disorders are those disorders occurring as file:///C|/Documents%20and%20Settings/ASUS/M. NREM. Drowsy. somatic. Sleep disorders are categorized into primary and secondary sleep disorders. Medium depth of sleep. occupies about half the night in adults. REM. Stage 4 (13% of total sleep time) Increased delta wave activity over stage 3.e. Figure 9-1 illustrates a normal sleep stage P.Ovid: Blueprints Psychiatry Transvestic fetishism Voyeurism Sexual excitement (in heterosexual men) is derived from fantasy or behavior involving wearing women's clothing Sexual excitement is derived from fantasy or behavior involving the observation of unsuspecting individuals undressing.pter%209%20-%20Miscellaneous%20Disorders. Serves as a transition stage between REM and delta sleep. or having sex ▪ TABLE 9-7 Sleep Stages NREM (75% of total sleep time) Stage 0 Stage 1 (5% of total sleep time) Stage 2 (45% of total sleep time) Awake Very lighta sleep.. a Depth of sleep as used here is not a precise term but generally refers to ease of arousability (i. however. the ease of arousability is caused in part by the type of stimulus used (e. EEG is active. deeper sleep than stage 2. rapid eye movement. naked. REM (25% of total sleep time) Dream sleep. electroencephalographic.g. EEG demonstrates sleep spindles and K-complexes. how hard would it be to awaken an individual from a particular stage). noise vs touch). and general performance. Delta (slow-wave sleep) comprises stages 3 and 4 Stage 3 (12% of total sleep time) Consists of a moderate amount of delta wave activity. mimicking that of the waking stage. non-rapid eye movement. SLEEP DISORDERS Sleep disorders are illnesses related to alterations in the sleep-wake cycle (Table 9-7) and often have effects on mood.htm (8 of 12) [30/01/2009 06:22:03 ‫]ﻡ‬ .

Table 9-9 defines the DSM-IV determined key characteristics of each disorder.g. (A) This graph represents falling asleep at 11:00 PM and entering non-rapid eye movement (REM) sleep stage 1. The cycle is repeated several times with REM sleep occurring at approximately 90-minute intervals in healthy adults.. medical illness. Chronic insomnia is not an official DSM-IV category but is a clinical category arising from both primary and secondary insomnia and mixtures of the two. Fig. The night's sleep progresses with the deeper stages of non-REM sleep (slow-wave sleep or delta sleep comprising stages 3 and 4 non-REM sleep) occurring more intensely in the early portion of the night. 1988. social stress (work.Ovid: Blueprints Psychiatry a direct result of disturbances in the sleep-wake cycle. none is more prevalent in psychiatry than insomnia either of primary origin or associated with other conditions such as anxiety. Factors increasing the risk for chronic insomnia include advancing age. Figure 9-1 • The stages of sleep through one night. Insomnia can generally be considered chronic if it is of greater than 6 months' duration.g. An estimated 15% of people have chronic insomnia. Cognitive-behavioral therapy and relaxation therapy may be helpful. etc. (B) Electroencephalographic rhythms during the stages of sleep.) Dyssomnias are five primary sleep disorders consisting of disturbances in initiating and maintaining sleep. caffeine).. depression. feeling rested or refreshed after sleep.. 1. and slow-wave sleep declines as the night progresses. file:///C|/Documents%20and%20Settings/ASUS/M. psychiatric illness. depression) resulting from general medical conditions (e. or psychoactive substance use. somatic pain) or substance use (e. relationships.htm (9 of 12) [30/01/2009 06:22:03 ‫]ﻡ‬ . and female gender. (Adapted from Home.).pter%209%20-%20Miscellaneous%20Disorders.. Secondary sleep disorders are a consequence of other mental disorders (e. or sleeping excessively. CHRONIC INSOMNIA Of the sleep disorders. REM sleep increases in duration. They are divided into two categories: dyssomnias and parasomnias.1..g. The treatment of chronic insomnia remains a major challenge.

Daytime naps relieve sleepiness. Sleep disturbance caused by a mismatch between a person's intrinsic circadian rhythm and external sleep-wake demands. Parasomnias Nightmare disorder Repeated episodes of scary dreams that wake a person from sleep. and regular exercise may also prove beneficial. either sleeping too long at one setting or persistent daytime sleepiness not relieved by napping Narcolepsy Sleep attacks during the daytime coupled with rapid eye movement sleep intrusions or cataplexy (sudden. Improved sleep hygiene. Antidepressants may also have some effect but may also cause insomnia. or sleeping but feeling as if one has not rested during sleep Excess sleepiness..69 ▪ TABLE 9-9 Primary Sleep Disorders Dyssomnias Primary insomnia Primary hypersomnia Difficulty falling asleep or staying asleep. There is a risk of benzodiazepine dependence from chronic use of benzodiazepines. Breathing-related sleep disorder Circadian rhythm sleep disorder Abnormal breathing during sleep leads to sleep disruption and daytime sleepiness. avoidance of caffeine. reversible bilateral loss of skeletal muscle tone).. file:///C|/Documents%20and%20Settings/ASUS/. ▪ TABLE 9-8 Sleep Disorders Primary Sleep Disorders Dyssomnias Primary insomnia Primary hypersomnia Narcolepsy Breathing-related sleep disorder Circadian rhythm sleep disorder Parasomnias Nightmare disorder Sleep terror disorder Sleepwalking disorder Sleep disorder related to another mental disorder Sleep disorder caused by a general medical condition Substance-induced sleep disorder Secondary Sleep Disorders P.ter%209%20-%20Miscellaneous%20Disorders.Ovid: Blueprints Psychiatry Modest effects have been noted for sleeping agents of various classes. in the form of regular sleep-wake cycles. usually occur during rapid eye movement sleep.htm (10 of 12) [30/01/2009 06:22:04 ‫]ﻡ‬ .

and single-physician structured treatment.htm (11 of 12) [30/01/2009 06:22:04 ‫]ﻡ‬ . ● Factitious disorder is characterized by the willful production of symptoms of illness in order to assume the sick role.Ovid: Blueprints Psychiatry Sleep terror disorder Repeated episodes of apparent terror during sleep. KEY POINTS ● Somatization disorder is a type of somatoform disorder.ter%209%20-%20Miscellaneous%20Disorders.. file:///C|/Documents%20and%20Settings/ASUS/. Sleepwalking disorder Recurrent sleepwalking. ● Treatment of somatization disorder includes cognitive-behavioral therapy. PARASOMNIAS Parasomnias are a triad of sleep disorders associated with complex behavioral events that occur during sleep or that arouse a person from sleep. ● Paraphilias are sexual behaviors or interests that are considered culturally unusual. or cry out and appear extremely frightened.. ● The symptoms of somatization disorders are subconscious in origin. individuals may sit up. ● Sexual dysfunctions are categorized according to the phase of the sexual response cycle during which they occur or to the presence of pain. Occurs during delta sleep. antidepressants. often coupled with other complex motor activity. They do not usually awaken during the attack. The disorders are defined in Table 9-9. ● The primary sleep disorders include the dyssomnias and the parasomnias. scream.

file:///C|/Documents%20and%20Settings/ASUS/. This should be differentiated from somatoform disorders (which are not willful) and malingering..htm (12 of 12) [30/01/2009 06:22:04 ‫]ﻡ‬ ..Ovid: Blueprints Psychiatry FACTITIOUS DISORDERS A factitious disorder is one in which an individual willfully produces signs or symptoms of a medical or psychiatric illness to assume the sick role and its associated gratifications.ter%209%20-%20Miscellaneous%20Disorders.. which is simply lying about signs or symptoms to obtain gains different from those obtained by assuming the sick role (e.g. to avoid the military or for monetary gain).

5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 10 . There is considerable evidence that low central nervous system serotonin is associated with increased suicide risk. but the concordance rate for suicide in monozygotic twins is nearly 10-fold that of dizygotic twins. Cowan.. have been associated with suicide risk. Ronald L. Alterations in the tryptophan hydroxylase gene. EPIDEMIOLOGY Suicide is the eighth leading cause of death in the United States. The overall suicide rate has remained stable in the United States during the past 15 years. Approximately 80 people commit suicide each day in the United States (30.Special Clinical Settings Chapter 10 Special Clinical Settings SUICIDE ATTEMPTS NEURAL BASIS Emerging evidence has begun to reveal neurobiological contributors to suicidal behavior... Michael J. Many more people attempt suicide.000 per year). and altered serotonin receptors. the rate of teen suicide has risen dramatically in the last 50 years. file:///C|/Documents%20and%20Settings/ASUS/My. Although the rate of suicide in teenagers aged 15 to 19 is low compared with the general adult population. a key enzyme in serotonin synthesis.htm (1 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ . Title: Blueprints Psychiatry. Altered serotonin markers include reduced cerebrospinal fluid serotonin metabolites. Genetic influences have not been thoroughly explored.Ovid: Blueprints Psychiatry Authors: Murphy.%2010%20-%20Special%20Clinical%20Settings. reduced brain serotonin concentration.

Providers should also warn patients and their families that suicidal thinking may increase with antidepressant medication treatment. Gay and lesbian youth have two to three times the rate of attempted suicide compared to heterosexual adolescents.%2010%20-%20Special%20Clinical%20Settings. Men commit suicide about four times as often as women. Recent evidence suggests that suicidal risk may increase in children and adolescents who initiate treatment with antidepressant medication (for depression or other psychiatric conditions). hopelessness has been shown to be one of the most reliable indicators of long-term suicide risk. men are more successful at completing suicide. Women often overdose or attempt drowning.. In men. in women. perhaps because of their more lethal methods (shooting. and insurance agents). dentists. Antidepressant medication prescribing information in the United States now contains a black box warning cautioning providers to assess carefully the risks and benefits of antidepressant P.Ovid: Blueprints Psychiatry RISK FACTORS The overwhelming majority of people who commit suicide have a mental illness (most often a mood disorder or chronic alcoholism). law enforcement officers. and certain professional groups (physicians.htm (2 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ . hanging. Suicide risk increases with age. lawyers. The first-degree relatives of people who have committed suicide are at a much higher risk of committing suicide themselves. jumping). Suicide is more common among higher social classes. musicians. most suicides occur after age 55. Among psychological risk factors. especially during the first few months of treatment. whereas women attempt suicide about four times as often as men.71 treatment in children and adolescents. or adjusting the dosage of an antidepressant file:///C|/Documents%20and%20Settings/ASUS/My.. Because antidepressants may also transiently increase suicidality in adults as well. although they represent only 10% of the population. Married people have a lower risk of suicide than singles. biologic risk factors include altered serotonin markers. Overall. Periods of initiating. adult patients should also be cautioned regarding this possibility. suicides peak after age 45. Elderly individuals account for 25% of the suicides. tapering. The details of the association between antidepressant medication treatment and child and adolescent suicidality are unknown. As noted. whites.

and caregivers. Patients may also overtly deny suicidal intent. especially for lithium and similar mood stabilizers. physicians should very carefully consider the potentially fatal delayed consequences of psychiatric medication changes. As such. intent. use particularly violent means. and plans. and isolate themselves so as not to be found alive are at particularly high risk of future suicide completion. even when prior statements to intimates or caregivers indicate clear suicidal thinking or planning. and clozapine. with nonspecific complaints. Psychiatric history and mental status examination should explicitly address depressive symptoms. when used to treat schizophrenia. Two medications have thus far shown evidence for reducing suicide risk: lithium.%2010%20-%20Special%20Clinical%20Settings. CLINICAL MANIFESTATIONS History and Mental Status Examination Most often. It is important always to obtain further details from the patient and any witnesses to provide a full history of the antecedents and the suicidal act. The details of the suicide attempt are critical to understanding the risk of a future suicide.. overdose or wrist laceration). Occasionally. file:///C|/Documents%20and%20Settings/ASUS/My.htm (3 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ . families. such as suicidal thoughts. when used to treat bipolar disorder. Abrupt lithium discontinuation.Ovid: Blueprints Psychiatry medication may increase the risk of worsening depression or suicidality: these periods warrant extra scrutiny by patients. is associated with a greatly increased suicide risk for at least 1 year afterward.. a patient will present to a physician in a more subtle way.. however.e. Careful inquiry may reveal that the patient has taken an overdose of a medication with delayed lethality (such as acetaminophen). either because the patient or family indicates that such an event has occurred or because there is an acute medical or surgical emergency (i. Patients who have attempted suicide require thorough psychiatric evaluation. Patients who carefully plan the attempt. a suicide attempt is self-evident at presentation.

there is little solid empirical evidence to guide clinical intervention targeted at preventing suicide. however.. schizophrenia. and enlisting spouses. MANAGEMENT Suicidal ideation should always be taken seriously. the standard of care for suicidal individuals remains hospitalization or other secure treatment alternative file:///C|/Documents%20and%20Settings/ASUS/My. Psychosocial interventions targeted at preventing suicide do not have strong research support.%2010%20-%20Special%20Clinical%20Settings. Frequent meetings with treatment providers. Treatment of the underlying disorder or distress derives from accurate diagnosis: antidepressants or electroconvulsive therapy for depression. potentially toxic prescription pills). and a treatment alliance exists..htm (4 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ . eliminating the means of suicide (firearms.g. Most actively suicidal patients require hospitalization on a locked unit for their own safety.Ovid: Blueprints Psychiatry Differential Diagnosis Patients who attempt suicide most commonly suffer from depression. antipsychotics and/or mood stabilizers for bipolar disorder. alcoholism. or schizophrenia.. and the patient should be observed carefully for the risk of elopement. clear data are not yet available regarding the particular efficacy of a given medication or class in this regard (except for lithium for bipolar disorder and clozapine for schizophrenia). psychotic depression. Patients at lower risk of suicide can often be managed as outpatients if close follow-up is available. family members are supportive. or other family members are essential elements of outpatient treatment. or personality disorders (or comorbidities of these disorders). Patients who do not meet criteria for any of these disorders can and do attempt or commit suicide. and intervention and effective treatment can be lifesaving. Although it seems clear that treating an underlying psychiatric condition might reduce the suicide risk associated with that condition. Surprisingly. Until additional evidence-based findings emerge. Suicidal patients are often fraught with ambivalence over whether to live or die. hopelessness). partners. Potentially lethal items should be held securely by nursing staff. especially if they have any of the risk factors (e.

more often than not. CLINICAL MANIFESTATIONS History and Physical and Mental Status Examination file:///C|/Documents%20and%20Settings/ASUS/My. According to the US Department of Justice. 37% of women treated in emergency rooms for violent injuries were hurt by a current or former partner. Some studies estimate that nearly one-third of all women have been beaten by their husband at least once during their marriage. 44% visited an emergency room in the 2 years prior to their deaths. Pregnant women are at elevated risk for spousal abuse. RISK FACTORS There is a strong association between alcohol abuse and domestic violence.htm (5 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ .. The victims of abuse. most abusers lived in violent homes where they either witnessed or were themselves victims of battering. EPIDEMIOLOGY Spousal abuse is estimated to occur in 2 to 12 million US households.Ovid: Blueprints Psychiatry P.%2010%20-%20Special%20Clinical%20Settings. Many battered women are eventually murdered by their spouses or boyfriends. As children. Physical abuse or battering is most often perpetrated by a male on a female partner. are also products of violent homes. and many of the abused. Of women murdered by an intimate partner. and abuse also occurs in same-sex relationships.. SPOUSAL ABUSE Abuse between spouses or partners can take several forms: physical. have a history of alcohol or other drug abuse. sexual. More than 50% of abusers.72 coupled to treatment of associated psychiatric conditions. often directed at their abdomens. and emotional. but women do batter men.

financial.Ovid: Blueprints Psychiatry Many victims of abuse are reluctant to report abusive episodes because they fear retaliation. believe they are deserving of abuse. both partners must agree to treatment) or to enable the victim to leave the relationship. and material file:///C|/Documents%20and%20Settings/ASUS/My. fractures. Victims of abuse are often mistreated in ways that prevent them from escaping the abusive relationship. Physical examination should include examination of the skin for contusions (especially of the face and breasts) and a genital examination. or more severe trauma. Either option is difficult to achieve. Victims usually live with their assailants. and isolated by the abuser.. or do not believe that help will be effective. maligned. Patients who refuse help should be told what emergency services are available and how to access them. or the threat of further battering.%2010%20-%20Special%20Clinical%20Settings. Unless the patient is asked tactfully in the absence of the abuser. Unfortunately. psychological. Patients may present in the company of their abuser for the treatment of “accidental” lacerations. who are often their children. women are most at risk for serious injury or homicide when they attempt to leave the abusive relationship. Social agencies must be enlisted to aid in child protection and custody if the latter option is chosen.. They are intimidated. coerced. he or she is unlikely to reveal the true cause of injuries. ELDER ABUSE Approximately 10% of those older than age 65 are abused. fear of being alone. contusions. Mistreatment includes abuse and neglect and takes physical.” MANAGEMENT The goal of treatment is to end the violence (i.e. The mental status examination should take into account the appropriateness of the patient's and partner's reactions to the “accident. Attempts to leave an abusive relationship may be thwarted by financial concerns.htm (6 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ . the welfare of children..

Ovid: Blueprints Psychiatry forms. Treatment involves appropriate medical and psychiatric services and social and legal services. however. or when the following symptoms occur. The Diagnostic and Statistical Manual of Mental P... trouble sleeping. Clinicians should be alert to the signs of abuse. or other necessities or beat.htm (7 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ . As with spousal abuse. The symptoms of bereavement. 4th edition criteria limit normal bereavement to a 2-month period following the loss of a loved one. BEREAVEMENT Bereavement occurs following the death of a loved one. mimic to some degree those of major depression. and ruminating on the loss of the loved one. When symptoms of major depression predominate. the elder person is often reluctant to reveal the abuse. The abuser may withhold food. such as sad mood. Some states mandate reporting of elder abuse. loss of appetite. sexually molest.73 Disorders. a diagnosis of major depression should be considered.%2010%20-%20Special%20Clinical%20Settings. clothing. Symptoms suggesting major depression include: ● Increased guilt (not associated with behavior or actions related to the death of the loved one) ● Suicidal thinking or thoughts of death (other than feeling that one has a desire to join the loved one in death) ● Excess worthlessness ● Psychomotor retardation file:///C|/Documents%20and%20Settings/ASUS/My. or emotionally abuse the victim.

Treatment for uncomplicated bereavement is diverse. ● About 10% of individuals over age 65 suffer elder abuse. file:///C|/Documents%20and%20Settings/ASUS/My. ● Antidepressants may transiently increase the risk of suicide. which is considered a normal component of bereavement). KEY POINTS ● Suicide is a fatal complication of many psychiatric disorders.. and there is not sufficient evidence available to suggest that one form of therapeutic intervention is reliably superior to another.htm (8 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ . ● Hopelessness is a risk factor for attempting suicide.%2010%20-%20Special%20Clinical%20Settings. In bereaved individuals with depression. antidepressant medication is indicated.. ● About one third of females suffer spousal abuse.Ovid: Blueprints Psychiatry ● Severe impairment in ability to function ● Auditory or visual hallucinations (other than hearing the voice or image of the deceased.

..Ovid: Blueprints Psychiatry ● Normal bereavement lasts up to 2 months. file:///C|/Documents%20and%20Settings/ASUS/My.%2010%20-%20Special%20Clinical%20Settings. ● Antidepressant medications are indicated for the treatment of depression in bereaved individuals.htm (9 of 9) [30/01/2009 06:22:07 ‫]ﻡ‬ .

affective blunting... Ronald L.. For example. antipsychotics have in common their blockade of dopamine receptors and their potential for serious side effects if used inappropriately or without careful monitoring. hallucinations.. Typical antipsychotics are thought to be less effective than atypical antipsychotics in treating the negative psychotic symptoms of schizophrenia (e.g. although they differ in side-effect profiles and potencies. Cowan.g. Their relative potencies. This file:///C|/Documents%20and%20Settings/ASUS/My. As a class. mental retardation).Antipsychotics Chapter 11 Antipsychotics Antipsychotic medications are used commonly in medical and psychiatric practice. some forms of nonpsychotic behavioral dyscontrol (e. organic brain syndromes. social withdrawal).. bizarre behavior. The most commonly prescribed typical (first generation) antipsychotics and atypical (second generation) antipsychotics are listed in Tables 11-1 and 11-2. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 11 . Alzheimer's disease. Tourette's syndrome. In addition to their role in treating psychotic symptoms. side-effect profiles. and transient psychotic symptoms as they appear in patients with personality disorder. hallucinations in schizophrenia. Title: Blueprints Psychiatry. INDICATIONS Antipsychotics generally are effective in treating the positive symptoms of schizophrenia (e. MECHANISM OF ACTION The most prominent theory on the mechanism of action of antipsychotics is the dopamine hypothesis of schizophrenia. and major adverse reactions are also described. in Alzheimer's disease.htm (1 of 10) [30/01/2009 06:22:13 ‫]ﻡ‬ . delusions) regardless of the actual diagnostic category (Table 11-3).. Atypical antipsychotics have fewer extrapyramidal side effects at therapeutic doses compared to typicals. antipsychotics are used to treat bipolar disorder. Michael J. delirium. They are generally equally effective.g.chiatry/Chapter%2011%20-%20Antipsychotics. Typical antipsychotics have also been called neuroleptics for their tendency to cause movement disorders.Ovid: Blueprints Psychiatry Authors: Murphy. Clozapine (and perhaps other atypicals) are more effective than typical antipsychotics for the treatment of refractory psychotic disorders. posttraumatic stress disorder symptoms. akinesia. or secondary to cerebral toxicity or injury all respond to antipsychotic medications. amotivation.

and dopamine agonist drugs (e.g. It appears to be clear that dopamine physiology is only part of a much more complex underlying pathology. amphetamine) can induce or exacerbate existing psychosis. P.Ovid: Blueprints Psychiatry hypothesis purports that dopaminergic hyperactivity leads to psychosis (Fig. 11-1).htm (2 of 10) [30/01/2009 06:22:13 ‫]ﻡ‬ . Abnormalities in γ-aminobutyric acid and N-methyl D-aspartate receptors and cortical neural networks are present in patients with schizophrenia versus healthy controls.. A comprehensive neurophysiological model of the disorder is being developed via the synthesis of a growing scientific knowledge base from a wide variety of international neuroscientists. Daxolin) Trifluoperazine (Stelazine) Thiothixene (Navane) Haloperidol (Haldol) Fluphenazine (Prolixin) 150-800 mg 200-800 mg 100-400 mg 15-255 mg 8-32 mg 60-100 mg 5-20 mg 5-30 mg 5-30 mg 2-60 mg 100 100 50 10 10 10 5 5 2 2 High High Med Med Low Med Med Low Low Med High High Med Low Low Low Low Low Low Low High Med Med Med Low Med Low Low Low Low Low Low Med High Med High High High High High Rangea Potencyb Sedative Hypotensive Anticholinergic Extrapyramidal Symptoms file:///C|/Documents%20and%20Settings/ASUS/My. individuals with schizophrenia have an increased number of brain dopamine receptors..chiatry/Chapter%2011%20-%20Antipsychotics. A third generation of antipsychotics is likely to be developed based on discoveries of the therapeutic effects of γ-aminobutyric acid and N-methyl D-aspartate modulation. Evidence supporting a role for hyperdopaminergic states in schizophrenia (and presumably other psychotic conditions) is as follows: antipsychotic potency of traditional antipsychotics correlates highly with their potency of dopamine receptor blockade.75 ▪ TABLE 11-1 Typical Antipsychotics Therapeutic Dosage Drug Typical antipsychotics (dopamine antagonists) Thioridazine (Mellaril)c Chlorpromazine (Thorazine) Mesoridazine (Serentil)c Molindone (Moban) Perphenazine (Trilafon) Loxapine (Loxitane..

Arana GW. 2005. which accounts for the numerous side effects and the finding that their action in the brain is not well correlated with regions thought to give rise to psychotic symptoms. Dosages are generally lower for geriatric patients and for those who are taking interacting medications or have other medical problems. Fatemi SH... P. In Schatzberg AF. serotonin. 2nd Ed. Hyman SE. Washington. DC: American Psychiatric Press. Treatment of schizophrenia. 5th Ed. 100 mg of thioridazine is equivalent to 2 mg of haloperidol) and should not be confused with efficacy.76 ▪ TABLE 11-2 Atypical Antipsychotics Drug Aripiprazole (Abilify) Clozapine (Clozaril) Risperidone (Risperdal) Olanzapine (Zyprexa) Paliperidone (INVEGA) Quetiapine (Seroquel) Therapeutic Daily Dosage Range 10-30 mg 100-600 mg 4-6 mg 10-20 mg 3-9 mg 400-800 mg file:///C|/Documents%20and%20Settings/ASUS/My. Nemeroff CB. b Potency is indicated as relative milligram dose equivalents (i.. It is unclear whether this serotonin activity imparts antipsychotic efficacy.chiatry/Chapter%2011%20-%20Antipsychotics. Handbook of Psychiatric Drug Therapy. Adapted from Meltzer HY. c Because of fatal cardiac events. the action mechanisms of our current antipsychotics are often much broader than simple dopamine blockade. or some other chemical mechanism. Additionally.htm (3 of 10) [30/01/2009 06:22:13 ‫]ﻡ‬ . Some atypical antipsychotics also appear to have “mood-stabilizing” properties in bipolar disorder.e. Philadelphia: Lippincott Williams & Wilkins. now approved only for refractory schizophrenia. The atypical antipsychotic medications have prominent serotonin (5-hydroxytryptamine-2) receptor activity.Ovid: Blueprints Psychiatry Pimozide (Orap) 15-225 mg 1 Low Low Low High a Recommended initial starting dosages are lower than the therapeutic dosage. 1998. but the activity may affect mood and anxiety symptoms in patients with psychotic disorders and helps prevent extrapyramidal side effects. All typical antipsychotics are thought to be equally efficacious. It is unclear whether the mechanism of these effects is related to dopamine. et al. Based on Rosenbaum JF. eds. Textbook of Psychopharmacology.

Ovid: Blueprints Psychiatry Ziprasidone (Geodon) 80-160 mg TYPICAL ANTIPSYCHOTICS (DOPAMINE ANTAGONISTS) The antipsychotic potency of typical antipsychotics (and risperidone) correlates with their affinity for the D2 receptor. Handbook of Psychiatric Drug Therapy. may have an initial sedative effect. frontal cortex. especially lower-potency medications. and limbic areas. Delusional disorders Childhood psychoses Posttraumatic stress disorder nightmares and flashbacks Possibly Effective Brief use for episodes of severe dyscontrol or apparent psychosis in some personality disorders file:///C|/Documents%20and%20Settings/ASUS/My. Arana GW. et al. 2005.. 5th ed.chiatry/Chapter%2011%20-%20Antipsychotics. Hyman SE.htm (4 of 10) [30/01/2009 06:22:13 ‫]ﻡ‬ . ▪ TABLE 11-3 Indications for Antipsychotic Drugs Effective Short-term use (< 3 mo) Exacerbations of schizophrenia Acute mania Psychotic depression Brief psychotic disorder Acute delirium Drug-induced psychoses resulting from hallucinogens and psychostimulants (not phencyclidine) Long-term use (> 3 mo) Schizophrenia Tourette's syndrome Bipolar disorder Huntington's disease Chronic psychoses related to neurological disorders Modified and reproduced from Rosenbaum JF.. Figure 11-2 is a schematic diagram of the proposed brain pathways affected by typical antipsychotics. their antipsychotic action is not immediate and takes several days to several weeks to peak. Dopamine-containing axons arising from brain stem nuclei (the ventral tegmental area and substantia nigra) project to the basal ganglia. Philadelphia: Lippincott Williams & Wilkins. Typical antipsychotic drugs and risperidone strongly block D2 receptors. Blockade of dopamine in the cortical and limbic areas results in reduction in psychotic symptoms. whereas blockade of dopamine in the basal ganglia produces extrapyramidal side effects. Although antipsychotics.

2nd Ed.chiatry/Chapter%2011%20-%20Antipsychotics. Neuroscience: Exploring the Brain. (Reproduced with permission from Bear MF.. 2001.htm (5 of 10) [30/01/2009 06:22:13 ‫]ﻡ‬ . Philadelphia: Lippincott Williams & Wilkins. Parasido MA.) P. The mesocorticolimbic dopamine system arises in the ventral tegmental area and has been implicated in the cause of schizophrenia. Connors BW. A second dopaminergic system arises from the substantia nigra and is involved in the control of voluntary movement by the striatum.Ovid: Blueprints Psychiatry Figure 11-1 • The dopaminergic diffuse modulatory systems of the brain.77 file:///C|/Documents%20and%20Settings/ASUS/My..

htm (6 of 10) [30/01/2009 06:22:13 ‫]ﻡ‬ . atypicals block serotonin receptors of the 5-hydroxytryptamine-2 subtype. it is not used until patients have failed at least two other antipsychotics. olanzapine. ATYPICAL ANTIPSYCHOTICS (SEROTONIN/DOPAMINE ANTAGONISTS) At present. clozapine is the only medication clearly shown to be superior in patients for whom other antipsychotics have failed. Figure 11-3 depicts the similarities and differences of the serotonin and dopamine systems. Choice of medication should be based on diagnosis. and ziprasidone are available and approved for acute agitation in schizophrenia. Risperidone is similar to typicals in that it is a very potent blocker of the D2 receptor with relatively less serotonin activity than other atypicals. however. which are given intramuscularly every 2 to 4 weeks for maintenance treatment of chronic psychosis (e. side-effect profile (patient tolerance). prior patient or family member response.. The oral preparations of the atypical antipsychotics are usually considered first line for acute psychosis. Intramuscular forms of aripiprazole.e. Antipsychotics are classified as atypical when they produce fewer movement side effects than typical antipsychotics. chronic schizophrenia).chiatry/Chapter%2011%20-%20Antipsychotics. haloperidol.Ovid: Blueprints Psychiatry Figure 11-2 • Pathways affected by typical antipsychotics. CHOICE OF MEDICATION Antipsychotic medications are most commonly chosen for the acute treatment of psychosis in both mood and psychotic disorders. elixir or intramuscular. in the United States.. there are seven atypical antipsychotics. file:///C|/Documents%20and%20Settings/ASUS/My. In addition to dopamine receptor blockade. Fluphenazine. or intramuscular depot availability). phase of the illness. likelihood of adherence and available form (i. Because of clozapine's serious side effects..g. At present. and risperidone are available in depot (or other long-acting) preparations.. Serotonin receptor blockade conveys some protection against extrapyramidal side effects and may impart antipsychotic efficacy.

specifying not only the diagnosis but also the phase of the illness for which a drug is approved (e. Choice of medication is often. the manic phase of bipolar disorder). quetiapine. Federal Food and Drug Administration (FDA). The initial phases of the study have confirmed current knowledge that antipsychotics are only partly effective in populations of patients. particularly because of intolerable side effects both in typicals and atypicals.chiatry/Chapter%2011%20-%20Antipsychotics. Metabolic and neurological reactions are particularly important.htm (7 of 10) [30/01/2009 06:22:13 ‫]ﻡ‬ . The FDA approval process often lags behind state-of-theart psychopharmacology. Neurological disorders such as akathisia file:///C|/Documents%20and%20Settings/ASUS/My. It is now recommended that one obtain a baseline body mass index and fasting blood glucose prior to initiating an atypical antipsychotic because of the risk of weight gain and diabetes. have been shown to differ markedly: movement disorder side effects are more common with typicals. olanzapine. A major multicenter clinical trial is underway that aims to compare the effectiveness of the antipsychotics in order to provide evidence to guide treatment choice. The study has also shown that the typicals (represented in the study by the midrange potency drug perphenazine) and the atypicals (with the exception of clozapine) have comparable rates of effectiveness as measured by rates of all-cause discontinuation (less than one-third of patients remained on any of the initial randomized drug at the end of the 18-month study either because the first drug was intolerable or did not work). The side effects of the agents.78 from the U. is being performed and published in phases over years.Ovid: Blueprints Psychiatry Figure 11-3 • Pathways affected by atypical antipsychotics. but not required. Much prescribing is done “off-label” based on available research and clinical experience. however. to be guided by approvals that have been obtained P. risperidone.. The study. The indications for some antipsychotics have recently broadened to include the treatment of various phases of bipolar disorder even when there is no psychosis present. Aripiprazole. known as Clinical Antipsychotic Trials of Intervention Effectiveness. for example.. Future phases will include the atypical aripiprazole and will look at the effect that patient support programs have on adherence and effectiveness.g. Olanzapine-fluoxetine in combination and quetiapine are approved for treatment of bipolar depression. THERAPEUTIC MONITORING Patients on antipsychotics should be monitored closely for adverse drug reactions. Phase 2 of Clinical Antipsychotic Trials of Intervention Effectiveness revealed superiority of clozapine over other atypicals in terms of all-cause discontinuation with 44% of the clozapine patients remaining on the drug at 18 months. Approved indications have become increasingly specific. and ziprasidone are all approved for use in the manic phase of bipolar disorder. chlorpromazine.. and sedation or metabolic effects more common with atypicals.S.

chlorpromazine) have the greatest anticholinergic side effects such as dry mouth. The duration of therapy depends on the nature and severity of the patient's illness. Common side effects of typical and atypical antipsychotics are described in the information to follow.chiatry/Chapter%2011%20-%20Antipsychotics. urinary retention. Reduced Seizure Threshold file:///C|/Documents%20and%20Settings/ASUS/My. such as schizophrenia. Patients who cannot bear the side effects of medications are nonadherent and suffer greater rates of relapse and recurrence.htm (8 of 10) [30/01/2009 06:22:13 ‫]ﻡ‬ . maintenance therapy should be used only after a careful risk-to-benefit analysis with the patient and involved family. especially in elderly individuals. require maintenance antipsychotic therapy.. Certain side effects such as sedation can be useful to a patient with insomnia or severe agitation but can also limit functioning.79 Anticholinergic Side Effects Low-potency.Ovid: Blueprints Psychiatry (restlessness). Although approximately 40% of patients will not respond to a particular antipsychotic. A comparison of side-effect profiles for commonly used typical antipsychotics is provided in Table 11-1. and blurred vision. SIDE EFFECTS AND ADVERSE DRUG REACTIONS Side effects of antipsychotics are a major consideration in physician prescribing. P. and extrapyramidal symptoms can happen with most antipsychotics but are more common with typical antipsychotics.g. typical antipsychotics (e. Individuals taking clozapine only must have frequent white blood cell counts to monitor for the development of agranulocytosis. as all antipsychotics appear to modestly lower seizure threshold. Clozapine levels are also frequently used to determine adherence and correlate efficacy with levels. or patients on other anticholinergic agents. neuroleptic malignant syndrome. the typicals with high anticholinergic activity and high antidopamine activity have low incidence of extrapyramidal symptoms. nonadherence (either full or partial) is often the cause of apparent therapeutic failure.. Further discussion of neurological side effects is found in Chapter 16.g.. Many disorders. constipation. those with organic brain syndromes. anticholinergic delirium may occur. Patients taking any antipsychotic should be carefully monitored for seizure activity. muscle stiffness) are related to an imbalance between dopamine and acetylcholine blockade.. Clozapine must be discontinued immediately in patients demonstrating this potentially fatal reaction. Because extrapyramidal side effects (e. Because of the serious sequelae associated with long-term antipsychotic use. Haloperidol levels have some utility in patients who have side effects at low doses or who fail to respond to high doses. Blood levels have generally been of little use in monitoring antipsychotic efficacy but may be useful in assessing adherence. In some cases.

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Low-potency typical antipsychotics and clozapine are associated with lowering seizure threshold. Seizures resulting from antipsychotic therapy are treated by changing medications, lowering the dose, or adding an antiseizure medication.

Hypotension
Orthostatic hypotension is particularly common with low-potency agents and risperidone. The hypotensive effect of antipsychotics is generally caused by α-receptor blockade.

Agranulocytosis
Agranulocytosis has been associated most commonly with clozapine. Because of the potentially fatal nature of this adverse effect, clozapine distribution is regulated and requires a regular complete blood count with absolute neutrophil count to monitor for neutropenia.

Cardiac Side Effects
Ziprasidone, low-potency typical antipsychotics (particularly thioridazine and mesoridazine), and risperidone may cause QT prolongation (with risk of torsade de pointes). Nonspecific electrocardiographic changes may also occur with certain antipsychotic medications (particularly with clozapine and olanzapine). Clozapine can cause a myocarditis, which is rare, but most commonly occurs early in treatment.

Metabolic Effects
Although patients with psychotic disorders are known to have higher rates of obesity and diabetes mellitus independent of medication therapy, studies have indicated that atypical antipsychotic medications (particularly olanzapine and clozapine) are associated with high rates of weight gain, dyslipidemia, and may be associated with adult-onset diabetes.

Movement Disorders
Movement disorders such as dystonia, extrapyramidal symptoms, akathisia, neuroleptic malignant syndrome, and tardive dyskinesia occur most commonly with high-potency typical antipsychotics (e.g., haloperidol) and are discussed further in Chapter 16.

Other Side Effects
Skin and ocular pigmentation are common side effects of neuroleptics, as is increased photosensitivity. Thioridazine can cause pigmentary retinopathy at high doses. Increased prolactin levels (and sequelae) may also occur. Quetiapine may increase the risk of developing cataracts.

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KEY POINTS

Typical (first generation) and atypical (second generation) antipsychotics are used to treat the psychotic symptoms of a wide range of disorders.

Typical and atypical drugs appear to be equally effective (with the exception of clozapine, which may be the most effective for refractory schizophrenia) but differ in D2 receptor potency and side effects.

Antipsychotics can have serious neurological and metabolic side effects and should be carefully prescribed and monitored.

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Authors: Murphy, Michael J.; Cowan, Ronald L. Title: Blueprints Psychiatry, 5th Edition

Copyright ©2009 Lippincott Williams & Wilkins

> Table of Contents > Chapter 12 - Antidepressants and Somatic Therapies

Chapter 12 Antidepressants and Somatic Therapies

Antidepressants are used commonly in medical and psychiatric practice. As a class, antidepressants have in common their ability to treat major depressive illness. Most antidepressants are also effective in the treatment of panic disorder and other anxiety disorders. Some anti-depressants effectively treat obsessive-compulsive disorder (OCD) and a variety of other conditions (see indications to follow).

The most commonly prescribed antidepressants are listed in Table 12-1. Antidepressants are subdivided into groups based on structure or prominent functional activity: selective serotonin-reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs), and other antidepressant compounds with a variety of mechanisms of action.

Antidepressants are typically thought to act on either the serotonin or norepinephrine systems, or both (Fig. 12-1). Choice of medications typically depends on diagnosis, history of response (in patient or relative), and the side-effect profile of the medication. Antidepressant effects are typically not seen until 2 to 4 weeks into treatment. Side effects must be carefully monitored, especially for TCAs and MAOIs.

INDICATIONS
Table 12-2 lists the indications for antidepressants. The main indication for antidepressant medications is major depressive disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Antidepressants are used in the treatment of all subtypes of depression, including the depressed phase of bipolar disorder, psychotic depression (in combination with an antipsychotic medication), atypical depression, and seasonal depression (see Chapter 2). Antidepressants are also indicated for the prevention of recurrent depressive episodes.

Antidepressant medications may be effective in the treatment of patients with dysthymic disorder, especially when there are clear neurovegetative signs or a history of response to antidepressants.

Panic disorder with or without agoraphobia has been shown to respond to SSRIs, MAOIs, TCAs, and high-potency

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benzodiazepines (alprazolam and clonazepam).

OCD has been shown to respond to the serotoninselective tricyclic clomipramine (Anafranil) and to SSRIs at high doses (e.g., fluoxetine at 60 to 80 mg per day). Obsessions tend to be more responsive to pharmacotherapy than compulsions. Symptoms of OCD respond more slowly than symptoms of major depression. Trials of 12 weeks or more are needed before a medication can be ruled a failure for a patient with OCD.

The binging and purging behavior of bulimia has been shown to respond to SSRIs, TCAs, and MAOIs in several open and controlled trials. Because SSRIs have the most benign side-effect profile of these medications, they are often the first-line psychopharmacologic treatment.

MECHANISMS OF ACTION
Antidepressants are thought to exert their effects at particular subsets of neuronal synapses throughout the brain. Their major interaction is with the monoamine neurotransmitter systems (dopamine, norepinephrine, and serotonin). Dopamine, norepinephrine, P.81

and serotonin are released throughout the brain by neurons that originate in the ventral brain stem, locus ceruleus, and the raphe nuclei, respectively (Figs. 11-1, 12-1 and 12-2). These neurotransmitters interact with numerous receptor subtypes in the brain that are associated with the regulation of global state functions including appetite, mood states, arousal, vigilance, attention, and sensory processing.

▪ TABLE 12-1 Commonly Prescribed Antidepressants
Drug (Brand Name) Selective serotonin reuptake inhibitors Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine (Luvox) Citalopram (Celexa) Escitalopram (Lexapro) Serotonin-norepinephrine reuptake inhibitors 20 mg 50-150 mg 20 mg 50-150 mg 20-40 mg 10 mg 80 mg 300 mg 50 mg 300 mg 60 mg 30 mg Usual Daily Dosagea Extreme Daily Dosagea

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Venlafaxine (Effexor) Duloxetine (Cymbalta) Serotonin receptor agonists and antagonists Trazodone (Desyrel) Nefazodone Norepinephrine-dopamine reuptake inhibitors Bupropion (Wellbutrin) Tricyclic antidepressants Nortriptyline (Pamelor) Imipramine (Tofranil) Desipramine (Norpramin) Clomipramine (Anafranil) Monoamine oxidase inhibitors Selegiline (EMSAM patch) Tranylcypromine (Parnate) Phenelzine (Nardil) Isocarboxazid (Marplan) Other antidepressants Mirtazapine (Remeron)

75-150 mg 40-60 mg

450 mg 120 mg

200-400 mg 200-450 mg

600 mg 600 mg

200-300 mg

450 mg

75-100 mg 150-200 mg 150-200 mg 150-200 mg

150 mg 300 mg 300 mg 250 mg

6-12 mg 30-50 mg 45-60 mg 30-50 mg

12 mg 90 mg 90 mg 90 mg

15-45 mg

60 mg

a

Geriatric patients generally require lower doses.

Modified and reproduced with permission from Rosenbaum JF, Arana GW, Hyman SE, et al. Handbook of Psychiatric Drug Therapy, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.

SSRIs act by binding to presynaptic serotonin reuptake proteins, thereby inhibiting reuptake and increasing the levels of serotonin in the synaptic cleft. TCAs act by blocking presynaptic reuptake of both serotonin and norepinephrine. MAOIs act by inhibiting the norepinephrine presynaptic enzyme (monoamine oxidase) that catabolizes norepinephrine, dopamine, and serotonin, thereby increasing the P.82

levels of these neurotransmitters presynaptically (Fig. 12-3). These immediate mechanisms of action are not sufficient to explain the delayed antidepressant effects (typically 2 to 4 weeks). Other, unknown mechanisms must play a role in the

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successful psychopharmacologic treatment of depression.

Figure 12-1 • The noradrenergic diffuse modulatory system arising from the locus ceruleus. The small cluster of locus ceruleus neurons project axons that innervate vast areas of the central nervous system, including the spinal cord, cerebellum, thalamus, and cerebral cortex.

(Reproduced with permission from Bear MF, Connors BW, Parasido MA. Neuroscience: Exploring the Brain, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2001.)

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Figure 12-2 • The serotonergic diffuse modulatory systems arising from the raphe nuclei. The raphe nuclei, which are clustered along the midline of the brain stem, project extensively to all levels of the central nervous system.

(Reproduced with permission from Bear MF, Connors BW, Parasido MA. Neuroscience: Exploring the Brain, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2001.)

▪ TABLE 12-2 Indications for Antidepressants

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Effective Major depressive disorder Bipolar depression (acute treatment) Panic disorder Social phobia Generalized anxiety disorder Posttraumatic stress disorder Obsessive-compulsive disorder (e.g., clomipramine and selective serotonin-reuptake inhibitors) Depression with psychotic features in combination with an antipsychotic drug Bulimia nervosa Neuropathic pain (tricyclic drugs and noradrenergic reuptake inhibitors) Insomnia (e.g., trazodone, amitriptyline) Enuresis (imipramine best studied) Atypical depression (selective serotonin-reuptake inhibitors or monoamine oxidase inhibitors) Attention-deficit disorder with hyperactivity (e.g., desipramine, bupropion) Probably effective Narcolepsy Organic mood disorders Pseudobulbar affect (pathological laughing or crying) Possibly effective Personality disorders Fibromyalgia Adapted with permission from Rosenbaum JF, Arana GW, Hyman SE, et al. Handbook of Psychiatric Drug Therapy, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.

CHOICE OF MEDICATION
Despite some studies indicating that some antidepressants are more capable of producing remission, P.83

the majority of the evidence indicates that all antidepressants have roughly the same efficacy in treating major depressive

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but this idea remains unproven. (Reproduced with permission from Bear MF. bupropion.) Antidepressants are relatively contraindicated in the manic or mixed episodes of bipolar disorder. these medications have very low sedative. SSRIs. nortriptyline and desipramine have the least sedative. Philadelphia: Lippincott Williams & Wilkins.htm (7 of 12) [30/01/2009 06:22:20 ‫]ﻡ‬ . or prostatic hypertrophy. Among the TCAs. Parasido MA. anticholinergic. and orthostatic hypotensive effects..Ovid: Blueprints Psychiatry episodes. glaucoma.idepressants%20and%20Somatic%20Therapies. 2001. Neuroscience: Exploring the Brain. Compared with TCAs and MAOIs. constipation. and orthostatic hypotensive effects. Figure 12-3 • Antidepressant drugs and the biochemical life cycles of norepinephrine and serotonin. healthier people. and mirtazapine are the most well tolerated antidepressants and are generally thought of as first-line agents for major depression.. nongeneric medications). file:///C|/Documents%20and%20Settings/ASUS/M. especially if cost is a consideration (tricyclics and other antidepressants available in generic form can be much less costly than newer. They can be used as first-line agents in younger. particularly in subtypes of patients with depression. Studies historically used response as measured by a depression rating scale to antidepressants. There are several treatment algorithms available for the pharmacological treatment of depression. 2nd Ed. anticholinergic. venlafaxine. These agents should be considered for use especially in patients with cardiac conduction disease. More research must be done in this area to determine the relative rates of depression remission. duloxetine. more recent studies have more strictly looked at remission. Connors BW. Higher rates of remission may be achieved with combinations of antidepressants.

insomnia or sedation. antidepressant therapy of a first episode of unipolar depression should continue for 6 months. dosage and length of trial are often limited by side effects (or noncompliance). Patients on antidepressants should be monitored carefully for side effects or adverse drug reactions (listed under Side Effects and Adverse Drug Reactions). should be carefully monitored for increased suicidal thinking associated with antidepressant medication treatment. is available and has demonstrated efficacy in treating depression. or addition of a second antidepressant is helpful in treating refractory depression. or in those with atypical depressions or social phobia (MAOIs or SSRIs are most effective). at its usual daily dosage of 6 mg. Patients with recurrent or chronic depression require longer or perhaps lifelong maintenance treatment. SIDE EFFECTS AND ADVERSE DRUG REACTIONS SSRIs Although specific SSRIs have slightly different side-effect profiles. but especially children and adolescents. methylphenidate). selegeline. anticholinergic. All patients. and orthostatic hypotensive effects) are the treatments of choice for OCD. they may also transiently increase suicidality during periods of initiation or cessation of treatment as well as during dosage adjustments. Generally. and are used in patients for whom SSRIs and tricyclics have failed. and delayed ejaculation/anorgasmia. in patients with a concomitant seizure disorder (MAOIs and SSRIs do not lower the seizure threshold).idepressants%20and%20Somatic%20Therapies. as a group. augmentation with lithium or triiodothyronine (liothyronine sodium [Cytomel]) or a psychostimulant (e. switching antidepressants. Increasing the dose. THERAPEUTIC MONITORING Approximately 50% of patients who meet DSM-IV criteria for major depression will recover with a single adequate trial (at least 6 weeks at a therapeutic dosage) of an antidepressant. Interestingly. SSRIs combined with file:///C|/Documents%20and%20Settings/ASUS/M. neuromuscular restlessness (resembling akathisia). The most common reasons for failed trials are inadequate dose and inadequate trial length..Ovid: Blueprints Psychiatry Because of the necessary diet restrictions and the risk of postural hypotension.84 preparation of a previously available MAOI. headache. Patients on most TCAs require serum level measurements to determine appropriate dosing. however. the traditional MAOIs (phenelzine and tranylcypromine) should be used most selectively. A new skin patch P. Although antidepressants may reduce the overall suicide rate by treating underlying depression. however. They can be quite effective. High-dose SSRIs and clomipramine (despite its high sedative. dietary restrictions are reportedly not necessary.. their main side effects are nausea.g..htm (8 of 12) [30/01/2009 06:22:20 ‫]ﻡ‬ .

TCAs should be avoided in patients with conduction system disease and should be used with extreme caution in patients who have overdosed on medication or have been recurrently suicidal. Specific TCAs have relative degrees of each of these effects. TRICYCLIC ANTIDEPRESSANTS TCAs in many patients are quite well tolerated..idepressants%20and%20Somatic%20Therapies. may require emergency medical attention. or more severe. The major side effects associated with TCAs are orthostatic hypotension. including dry mouth. QRS. At 6 mg daily. and third-degree heart block. cardiac toxicity. Many over-the-counter cold and pain remedies must also be avoided. and urinary hesitancy. and seizures. This is particularly worrisome in elderly patients. delirium. phenelzine can cause daytime somnolence. Treatment of hypertensive crisis. bundle branch block. Major complications from TCAs are rare in patients with normal hearts. blurred near vision. Improper diet can lead to severe hypertensive crises (tyramine crisis) with potential myocardial infarction or stroke. bupropion. and QT intervals. if severe. Anticholinergic toxicity can be mild. hallucinations. Orthostatic hypotension is the most common serious side effect of the TCAs. however..Ovid: Blueprints Psychiatry MAOIs are dangerous: a fatal serotonin syndrome may result. no dietary restrictions are required. including IV phentolamine (an α-blocker) or continuous IV nitroprusside infusion. Cardiac toxicity may limit the use of TCAs in some patients. ventricular tachycardia. or venlafaxine. who may be more prone to falls. first-.85 cream cheeses. Sexual dysfunction includes impotence in men and decreased sexual arousal in women. MONOAMINE OXIDASE INHIBITORS Patients who take traditional oral MAOIs are at risk for hyperadrenergic crises from the ingestion of sympathomimetic amines (such as tyramine) that fail to be detoxified because of inhibition of the gastrointestinal monoamine oxidase system. TCAs have quinidine-like effects on the heart. Foods that must be avoided include cured meats or fish. potentially causing sinus tachycardia. and overripe fruits. TCAs are less well tolerated overall than are SSRIs. second-. MAOIs cause a dose-related orthostatic hypotension: tranylcypromine can cause insomnia and agitation. red wine. but because of their side effects. constipation. with agitation. prolongation of PR. beer. and sexual dysfunction. supraventricular tachyarrhythmias. anticholinergic effects. motor restlessness. or ST and T-wave changes. ventricular fibrillation.htm (9 of 12) [30/01/2009 06:22:20 ‫]ﻡ‬ . The new selegiline patch carries the same risks as traditional oral MAOIs when used at 9 mg daily or above. all cheese except cottage and P. file:///C|/Documents%20and%20Settings/ASUS/M.

depressants%20and%20Somatic%20Therapies. Bupropion has a higher-than-average risk of seizures compared with other antidepressants. The risk of seizures is greatest above a daily dose of 450 mg or after a single dose of greater than 150 mg of immediate-release bupropion. Early findings suggest that VNS may influence the hippocampus. magnetic. Trazodone is prescribed rarely as a sole antidepressant but is often prescribed as an adjunct to an SSRI for sleep because it has strong sedative properties (at higher doses. In addition to its efficacy in treating major depression.e. file:///C|/Documents%20and%20Settings/ASUS/. Nefazodone and trazodone (Desyrel) are serotonin-modulating antidepressants. These methods are being studied particularly for treatment-resistant depression (i. there are a growing number of treatments available that use electrical. In addition to sedation. SOMATIC THERAPIES Although all psychotropic drugs are “somatic” in that they affect a part of the body (the brain). VAGUS NERVE STIMULATION Vagus nerve stimulation (VNS) therapy is approved for treatment-resistant major depression.. It will be discussed last after newer. Bupropion (Wellbutrin. It appears to have a low rate of sexual dysfunction but has been associated with serious hepatic abnormalities. The best studied and most well known of these treatments is electroconvulsive therapy (ECT. it is presumed that retrograde conduction of impulses from peripheral stimulation of the nerve influence central nervous system function.. Bupropion has a low incidence of sexual side effects. Nefazodone is similar to trazodone but is less sedating at therapeutic doses.htm (10 of 12) [30/01/2009 06:22:20 ‫]ﻡ‬ . Patients must be instructed to seek emergency treatment should such an erection occur. Effexor XR) and duloxetine (Cymbalta) are serotonin and noradrenergic reuptake inhibitors with a better side-effect profile than TCAs or MAOIs.Ovid: Blueprints Psychiatry OTHER ANTIDEPRESSANTS Venlafaxine (Effexor.. Wellbutrin SR. It is quite sedating in some individuals and has a low incidence of sexual dysfunction. Zyban) appears to work by inhibiting the uptake of dopamine and norepinephrine. colloquially known as “shock” therapy). trazodone can on rare occasions induce priapism (prolonged. Mirtazapine (Remeron) is classified as a modulator of norepinephrine and serotonin. bupropion has been shown to be effective in smoking cessation (marketed as Zyban) and attention-deficit disorder. or photic stimulation of the central nervous system to treat depression. episodes that do not respond to several medications serially or in combination). it serves as an antidepressant). Although the precise mechanisms of action of VNS in influencing depression are unknown. as well as the widely distributed neurotransmitters norepinephrine and γ-aminobutyric acid. more experimental therapies. painful penile erection) that can cause permanent damage.

electrical deep-brain stimulators have shown some early promising efficacy in small. The peripheral manifestations of seizure activity are blocked by the use of paralytics.. Light therapy can induce mania in susceptible individuals. formerly known as electric shock therapy. bulimia. uncontrolled trials of patients with refractory depression. controlled trials will be needed to determine the technique's true efficacy. anxiety disorders. it remains experimental. ● file:///C|/Documents%20and%20Settings/ASUS/. ECT also has some efficacy in refractory mania and in psychoses with prominent mood components or catatonia.000 lux is most effective. Bilateral ECT is more effective than unilateral ECT but produces more cognitive side effects. In the P. and memory for the event is blocked by the use of anesthetics and by seizure activity.Ovid: Blueprints Psychiatry DEEP-BRAIN STIMULATION Reversible. Phototherapy is administered using specially designed bright light boxes and has been shown effective in the treatment of the seasonal subtype of major depression (also known as seasonal affective disorder) and in nonseasonal depression as well. For now. implantable..500 to 10. Stimulation to parts of the frontal cortex and subgenual cingulate has yielded positive results. ELECTROCONVULSIVE THERAPY Electroconvulsive therapy (ECT). PHOTOTHERAPY Phototherapy consists of the controlled administration of bright light to treat specific psychiatric illnesses. randomized. Modern ECT produces short-term memory loss and confusion. among others. KEY POINTS ● Antidepressants have multiple indications including various forms of depression. ECT appears to work via the induction of generalized seizure activity in the brain. Phototherapy is also used in the treatment of the delayed sleep phase syndrome and jet lag. early morning bright light therapy is superior to evening light in most individuals. is one of the oldest and most effective treatments for major depression.86 treatment of seasonal affective disorder. and OCD.htm (11 of 12) [30/01/2009 06:22:20 ‫]ﻡ‬ . Light intensity of 2. Large.depressants%20and%20Somatic%20Therapies.

all approved antidepressants reduce symptoms to a similar degree.Ovid: Blueprints Psychiatry Antidepressants act mainly on serotonergic and noradrenergic receptor systems. file:///C|/Documents%20and%20Settings/ASUS/..depressants%20and%20Somatic%20Therapies. ● VNS is used for treatment-refractory depression. ● Some antidepressants. require monitoring of serum levels. or psychostimulants. ● Antidepressants have side effects that vary according to class. for major depression.htm (12 of 12) [30/01/2009 06:22:20 ‫]ﻡ‬ . thyroid hormone.. ● Some antidepressants have been shown to be efficacious for particular disorders. Antidepressants for depression are often chosen based on side-effect profile and symptom constellation. particularly TCAs. ● The effects of antidepressants can be augmented by the addition of lithium.

They are indicated for long-term maintenance prophylaxis against depression and mania in bipolar individuals. Anticonvulsant medications (valproate.. patient tolerance. The term mood stabilizers traditionally refers to lithium. Mood stabilizers are also used for treatment of impulsive behavior in individuals without bipolar disorders. More recently. Ronald L. and therapeutic levels.. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 13 . and lamotrigine. Table 13-1 lists the traditional mood stabilizers.Mood Stabilizers Chapter 13 Mood Stabilizers Mood stabilizers are psychotropic medications that promote euthymia (a normal. Cowan. reasonably positive mood) in bipolar disorder. and a history of patient or file:///C|/Documents%20and%20Settings/ASUS/M.htm (1 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry Authors: Murphy. Title: Blueprints Psychiatry.. metabolic routes.e. nondepressed.ry/Chapter%2013%20-%20Mood%20Stabilizers. Michael J. subtype of bipolar disorder) and other clinical factors such as side effects. their dosage. The choice of mood stabilizer is based on a patient's particular psychiatric illness (i. This capacity was discussed in Chapter 11. it has been proven that some atypical antipsychotics have mood-stabilizing properties. meaning that they are able to treat and prevent the recurrence of manic or depressed phases of bipolar disorder. carbamazepine.. and carbamazepine) may also be useful in individuals experiencing seizure-related mood instability. lamotrigine. INDICATIONS Mood stabilizers are indicated acutely (in conjunction with antipsychotics) for the treatment of mania. They generally treat and prevent the recurrence of elevated (manic) or depressed moods. valproate.

their function is altered by lithium.htm (2 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ .88 renally cleared and can easily reach toxic levels in persons with altered renal function (e. and the G protein-coupled phosphoinositide systems-and. they may share a common mechanism of action that is yet to be elucidated. Conversely. can directly alter ion channel function. The range of neurotransmitters affected by these medications and their disparate modes of action suggest that mania may be controlled by altering the function of several different neurotransmitter systems. Some common and more serious side effects of mood stabilizers are listed in Table 13-3. Because norepinephrine and serotonin in the central nervous system (CNS) use G protein-coupled receptors as one of their mechanisms of action.ry/Chapter%2013%20-%20Mood%20Stabilizers. The mechanism of action of mood stabilizers in bipolar illness is unclear. Lithium alters at least two intracellular second messenger systems-the adenyl cyclase. Table 13-2 lists the major mood stabilizers and their most common indications. especially elderly individuals) or dehydration. as an ion.. lithium has been shown to reduce the incidence of completed suicide..g. cyclic adenosine monophosphate system.. It may be less effective in the treatment of the rapid cycling variant of bipolar disorder. Choice of Medication Lithium is indicated as a first-line treatment for regular cycling bipolar disorder in individuals with normal renal function. Lithium also alters γ-aminobutyric acid (GABA) metabolism. When used in the treatment of bipolar disorder.Ovid: Blueprints Psychiatry first-degree relative drug responsiveness. file:///C|/Documents%20and%20Settings/ASUS/M. LITHIUM Mechanism of Action Lithium's mechanism of action in the treatment of mania is not well determined. Lithium is also used to augment other antidepressants in unipolar depression. Lithium is P.

1 mEq/L 50-125 mg/L — 4-12 mg/L — are generally lower for geriatric patients.ry/Chapter%2013%20-%20Mood%20Stabilizers.500 mg/day 1000-2.500 mg/day 150-250 mg/day 600-1.htm (3 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . ▪ TABLE 13-2 Psychiatric Indications for Mood Stabilizersa Drug Lithium Acute mania Bipolar depression Long-term maintenance in bipolar disorder Augmentation of antidepressant medications Impulse dyscontrol Valproate Acute mania Long-term maintenance in bipolar disorder May be more effective in rapid-cycling bipolar disorder Impulse dyscontrol Uses file:///C|/Documents%20and%20Settings/ASUS/M. or patients with other medical problems. patients taking medications inhibiting metabolism of the drug.200 mg/day 600-1..Ovid: Blueprints Psychiatry ▪ TABLE 13-1 Common Mood Stabilizersa Therapeutic Serum Drugs Lithium carbonate Valproic acid Lamotrigine Carbamazepine Oxcarbazepine aDosages Starting Dosage 300 mg bid-tid 250 mg bid-tid 25 mg qd 100 mg bid-tid 150 mg bid Therapeutic Dosage 900-1.200 mg/day Concentration 0.6-1..

diarrhea. confusion.Ovid: Blueprints Psychiatry Carbamazepine Acute mania Long-term maintenance in bipolar disorder Impulse dyscontrol Lamotrigine Bipolar depression Long-term maintenance in bipolar disorder aSome indications are Food and Drug Administration approved. polyuria.ry/Chapter%2013%20-%20Mood%20Stabilizers. acne exacerbation. minor memory problems. ataxia.. and weight gain. gastrointestinal distress. sinus arrest. In addition.. Side Effects Common side effects of lithium therapy include tremor. VALPROATE file:///C|/Documents%20and%20Settings/ASUS/M. and death can occur. others are based on clinical experience and evidence. coma. Serum thyroid-stimulating hormone and creatinine levels should be checked at regular intervals. especially if they undergo an abrupt change in renal function. Therapeutic Monitoring Successful lithium therapy requires that the patient take daily dosages of the drug consistently. patients should be warned about toxicity and should be regularly assessed for side effects.htm (4 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . Additional monitoring is necessary in a patient with variable compliance or altered renal function. coarse tremor. excessive thirst. At toxic levels. Serum levels should be monitored regularly until a stable dosing regimen has been obtained. Approximately 5% of patients on long-term lithium therapy develop hypothyroidism because the lithium interferes with thyroid hormone production. The therapeutic effect generally occurs after 2 to 4 weeks of consistent use. Lithium has a narrow therapeutic window. and patients can develop toxicity at prescribed doses.

vomiting.ry/Chapter%2013%20-%20Mood%20Stabilizers. Valproate increases GABA synthesis. death Sinus arrest Sedation. diarrhea Benign leukocytosis Weight gain. thyroid abnormalities Alopecia. psoriasis Nausea.Ovid: Blueprints Psychiatry Mechanism of Action Valproate's mechanism of action is thought to be due in part to augmentation of GABA function in the CNS. fine tremor Abnormal TSH.89 ▪ TABLE 13-3 Drugs Used as Mood Stabilizers Drug Lithium Side-Effect Profile Therapeutic levels CNS: Endocrine: Cardiac: Renal: Dermatologic: Gastrointestinal: Hematologic: Other: Toxic levels CNS: Cardiac: Valproate Therapeutic levels CNS: Endocrine: Dermatologic: Somnolence. sinus arrhythmia Polyuria Acne. clinical hypothyroidism T-wave change.htm (5 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . decreases GABA breakdown. seizure. confusion.. and enhances its postsynaptic efficacy. ataxia. rash Ataxia.. coarse tremor. coma. tremor Menstrual irregularities. fluid retention file:///C|/Documents%20and%20Settings/ASUS/M. cognitive clouding. P.

ry/Chapter%2013%20-%20Mood%20Stabilizers.Ovid: Blueprints Psychiatry Hepatic: Gastrointestinal: Hematologic: Other: Toxic levels CNS: Cardiac: Idiosyncratic Hepatic: Gastrointestinal Hematologic: Carbamazepine Therapeutic levels CNS: Dermatologic: Cardiac: Hematologic: Gastrointestinal: Toxic levels CNS: Cardiac: Respiratory: Idiosyncratic Hematologic: Mild transaminitis Nausea. diplopia Rash Decreased atrioventricular conduction Benign leukopenia Nausea Somnolence. death Cardiac arrest Fatal hepatotoxicity Pancreatitis Agranulocytosis Ataxia. indigestion Thrombocytopenia. dizziness..htm (6 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . autonomic instability. coma. confusion. pancytopenia. aplastic anemia file:///C|/Documents%20and%20Settings/ASUS/M. death Atrioventricular block Respiratory depression Agranulocytosis. coma.. vomiting. sedation. platelet dysfunction Edema Ataxia.

dyspepsia Weight decrease. It is used off-label in treating general impulse dyscontrol. serious life-threatening rash Nausea. coma. central nervous system. Choice of Medication Valproate is indicated for the treatment of acute mania and is widely used in the maintenance phase of bipolar I disorder (Table 13-2). seizures. valproate can be initiated at a larger-than-usual dosage (20-25 mg/kg body file:///C|/Documents%20and%20Settings/ASUS/M.htm (7 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . nystagmus.ry/Chapter%2013%20-%20Mood%20Stabilizers. P. coordination abnormality. It is effective for the rapid-cycling and mixed variants of bipolar disorder.. Therapeutic Monitoring In otherwise physically healthy adults. infection. rhinitis CNS.Ovid: Blueprints Psychiatry Lamotrigine Therapeutic levels CNS: Dizziness. somnolence. death Intraventricular conduction delay Dysmenorrheal Chest pain Rash. vomiting. insomnia. anxiety.90 Its capacity to raise the seizure threshold allows it to be used to treat seizure disorders as well.. headache Endocrine: Cardiac: Dermatologic: Gastrointestinal: Other: Toxic levels CNS: Cardiac: Ataxia. It may not provide prophylaxis against depression in bipolar disorder or augment antidepressants.

Liver function tests should be checked at baseline and frequently during the first 6 months. Thrombocytopenia and impaired platelet function may also occur. mild ataxia. Lamotrigine is approved by the Food and Drug Administration for use in the maintenance and depressed phases of bipolar I disorder (lamotrigine is not approved for the acute treatment of mania because it appears to be less effective in this phase). and death can occur. Rapid (less than 7 days) decreases in manic symptoms can be achieved with this method. mild tremor.Ovid: Blueprints Psychiatry weight) for the acute treatment of a manic episode. fulminant pancreatitis.. valproate produces a variety of side effects. and agranulocytosis. Side Effects At therapeutic levels. The full effect of the medicine is generally not seen until 2 to 4 weeks of consistent daily dosing at a therapeutic level.ry/Chapter%2013%20-%20Mood%20Stabilizers. coma. including sedation. Lamotrigine in vitro has been shown to inhibit voltage-sensitive sodium channels. Serum levels should be monitored regularly until a stable blood level and dosing regimen have been obtained. Valproate usage carries with it the risk of idiosyncratic but serious side effects. cardiac arrest.htm (8 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . At toxic levels. This effect is believed to stabilize neuronal membranes and modulate presynaptic excitatory neurotransmitter release. confusion. These include fatal hepatotoxicity. this allows for rapid achievement of a therapeutic blood level. Choice of Medication file:///C|/Documents%20and%20Settings/ASUS/M. especially because the idiosyncratic reaction of fatal hepatotoxicity is most frequent in this time frame. A lower average daily oral dosage is then started the day after loading. known as Depakote loading. In the acute hospital setting. LAMOTRIGINE Mechanism of Action The mechanism of action of lamotrigine in bipolar disorder is unknown. and gastrointestinal distress..

valproic acid).. nausea. dizziness. A clinically useful assay for serum levels of lamotrigine is not available.ry/Chapter%2013%20-%20Mood%20Stabilizers. this medication should only be prescribed by a qualified psychiatrist.Ovid: Blueprints Psychiatry Although studies are still ongoing regarding the use of lamotrigine in bipolar disorder. It may also be more efficacious for rapid cycling. P. Side Effects Lamotrigine can commonly cause ataxia. Therapeutic Monitoring The therapeutic effect of lamotrigine is delayed by the need to gradually increase the dosage to a therapeutic level. Dosages are generally lowered for elderly individuals.91 CARBAMAZEPINE file:///C|/Documents%20and%20Settings/ASUS/M. The benefits are usually seen when dosage exceeds 150 mg for 2 to 4 weeks.. neurologist. diplopia. The development of serious allergic reactions (rash leading to Stevens-Johnson syndrome) to lamotrigine appears to be related to rapid-dose escalation or drug interactions. those with renal or other organ impairment..htm (9 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . Severe. The allergic reaction can begin as a simple rash and lead to Stevens-Johnson's syndrome. The rate of serious or life-threatening rashes is greater in the pediatric age group. potentially life-threatening allergic rashes have been reported with the use of lamotrigine. Generally. and vomiting. Dosages are started low (25 mg daily) and increased gradually (25 mg per week) to the average therapeutic dosage of 200 mg daily. blurred vision. or other provider who is aware of the complex drug interactions that exist particularly between valproic acid and lamotrigine. or when combined with interacting agents (i. it appears to be more effective in treating or preventing the depressive phase of bipolar I disorder than the manic phase.e.

Carbamazepine levels should be monitored regularly until a stable dosing regimen has been obtained. produces similar CNS side effects to lithium and valproate. signs of toxicity. autonomic instability. Side Effects Carbamazepine. and mild leukopenia are also common. blocking the neuron from repetitive firing. atrioventricular block.Ovid: Blueprints Psychiatry Mechanism of Action The mechanism of action of carbamazepine in bipolar illness is unknown. and aplastic anemia. prophylaxis against mania in bipolar disorder. Patients should be carefully monitored for rash. Carbamazepine also appears to indirectly alter central GABA receptors.y/Chapter%2013%20-%20Mood%20Stabilizers.htm (10 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . or evidence of severe bone marrow suppression.. At toxic levels. Carbamazepine has idiosyncratic side effects of agranulocytosis. Carbamazepine's efficacy in the prophylaxis and treatment of depression is not clear.. In addition. respiratory depression. daily dosing. It is also used in treating impulse dyscontrol. It is used in acute mania. at therapeutic levels. Choice of Medication Carbamazepine is generally considered to be an off-label (not Food and Drug Administration approved) second-line drug (after lithium and valproate) for the treatment of mania (Table 13-2). carbamazepine decreases the amount of transmitter release at presynaptic terminals. and coma can occur. rash. Carbamazepine blocks sodium channels in neurons that have just produced an action potential. Nausea. and may be more effective than lithium in rapid-cycling and mixed mania. file:///C|/Documents%20and%20Settings/ASUS/. Therapeutic Monitoring The therapeutic effects of carbamazepine are seen from 2 to 4 weeks after consistent. pancytopenia.

ANTIPSYCHOTIC MEDICATIONS AND BIPOLAR DISORDER Several atypical antipsychotic medications (Chapter 11) are also approved for use in bipolar disorder. and aripiprazole.. a few small.htm (11 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ . file:///C|/Documents%20and%20Settings/ASUS/. The efficacy of oxcarbazepine in treating the various stages of bipolar disorder has not been well proven. risperidone. ● Mood stabilizers have serious toxicities. so patients require regular monitoring. ziprasidone. ● Effective treatment is achieved through daily dosing at a therapeutic blood level. quetiapine. ● Mood stabilizers work by unknown but likely varied mechanisms.y/Chapter%2013%20-%20Mood%20Stabilizers.. Other studies suggest the drug may also be effective in the maintenance phase of bipolar disorder. controlled studies suggest that oxcarbazepine is effective in acute mania. They can be used as monotherapy or in conjunction with a traditional mood stabilizer to achieve more optimal mood stability. Atypical antipsychotics approved for the mood component of bipolar disorder include olanzapine. KEY POINTS ● Mood stabilizers are indicated for the treatment of all episodes of bipolar disorder. but.Ovid: Blueprints Psychiatry OXCARBAZEPINE Oxcarbazepine is an anticonvulsant that is structurally similar to carbamazepine but that has fewer side effects and drug interactions.

. file:///C|/Documents%20and%20Settings/ASUS/.htm (12 of 12) [30/01/2009 06:22:25 ‫]ﻡ‬ .y/Chapter%2013%20-%20Mood%20Stabilizers..Ovid: Blueprints Psychiatry Some atypical antipsychotics also have mood-stabilizing properties and can be used as monotherapy or in conjunction with more traditional mood stabilizers.

Benzodiazepines are used to treat a variety of anxiety disorders: panic disorder. the benzodiazepines are uniquely effective for the rapid relief of a broad spectrum of anxiety symptoms.. Ronald L. In psychiatry..older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics.. is used primarily in the treatment of generalized anxiety disorder. generalized anxiety disorder. and other medications (e.g.. Although benzodiazepines have a wide variety of clinical applications (e. antidepressants) are of utility in treating some forms of anxiety. file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C. and in the treatment of insomnia)..htm (1 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry Authors: Murphy. it does not appear to be effective in treating other types of anxiety (e. panic).Anxiolytics Chapter 14 Anxiolytics The medications discussed in this chapter have anxiolysis in common. Cowan.. Buspirone is a novel medication that. at present. in the treatment of status epilepticus. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 14 . as preanesthetics. as muscle relaxants. Title: Blueprints Psychiatry. anxiety associated with stressful life events (as in adjustment disorders with anxiety). BENZODIAZEPINES INDICATIONS Benzodiazepines are among the most widely used drugs in all of medicine. Michael J. they are used as the primary treatment of a disorder or as adjunct treatment to other pharmacologic agents.g.g.

there is evidence for reduced numbers of GABA receptors in the CNS of patients with anxiety disorders. There may also be reductions in the concentration of GABA in the cortex of this group. For example. Medications that alter monoamine function. benzodiazepines are used for the short-term treatment of insomnia.Ovid: Blueprints Psychiatry and anxiety that complicates depression (see Chapter 3). for the agitation of mania. P. as well as buspirone (see later) are also highly effective in treating some anxiety disorders.htm (2 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ . and psychotic disorders. GABA is a widespread inhibitory neurotransmitter with a complicated receptor structure. Emerging evidence in anxiety disorders suggests that altered GABA function is associated with anxiety. GABA is clearly not the only neurotransmitter implicated in susceptibility to anxiety disorders. and barbiturates. Because benzodiazepines are direct agonists at a rapidly responding ion channel. benzodiazepines. their mechanism of action is virtually instantaneous with their arrival in the CNS (in contrast to buspirone. In addition to this reduced density of GABA receptors in anxiety. The most likely mode of action of benzodiazepines in treating psychiatric illnesses is via their augmentation of GABA function in the limbic system.93 file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C. the GABA-B receptor appears to work by second messenger systems) (Figs. 14-1 and 14-2). having multiple binding sites for GABA. however. such as serotonin and norepinephrine reuptake inhibitors.. the remaining GABA receptors may show decreased or altered responsiveness to benzodiazepines. and in the treatment of catatonia (Table 14-1). for the treatment of alcohol withdrawal. dementia.older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics. MECHANISM OF ACTION Benzodiazepines appear to function as anxiolytics via their agonist action at the central nervous system (CNS) γ-aminobutyric acid (GABA) receptors (the GABA-A receptor regulates a chloride ion channel. In addition.. information to follow).

.htm (3 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ .older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics. Neuroscience: Exploring the Brain. (Reproduced with permission from Bear MF. 2001. Connors BW. ▪ TABLE 14-1 Psychiatric Uses for Benzodiazepines Anxiety disorders Generalized anxiety disorder Panic disorder Mood disorders Depression-related anxiety Depression-related insomnia file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C.Ovid: Blueprints Psychiatry Figure 14-1 • Neurotransmitter transporters. Parasido MA. Philadelphia: Lippincott Williams & Wilkins.. 2nd Ed.

..htm (4 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry Agitation in manic episode Adjustment disorders Treatment of adjustment disorder with anxiety Sleep disorders Short-term treatment of insomnia Miscellaneous Treatment of akathisia induced by neuroleptics Agitation from psychosis or other causes Catatonia (especially lorazepam) Alcohol withdrawal file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C.older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics.

older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics...Ovid: Blueprints Psychiatry file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C.htm (5 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ .

rate of onset. (Reproduced with permission from Bear MF. 2nd Ed. 2001. and clinically proven effectiveness. Philadelphia: Lippincott Williams & Wilkins. Table 14-2 illustrates the properties of some commonly used benzodiazepines and their common clinical uses. may produce a “high” feeling and are potentially more addictive. Benzodiazepines bind to a site on the GABA-A receptor that makes it much more responsive to GABA. Neuroscience: Exploring the Brain. Connors BW. effective half-life. Route of Metabolism file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C. Rate of Onset Fast-onset benzodiazepines. as is diazepam. Parasido MA. Although all benzodiazepines appear to function by common mechanisms..htm (6 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ . route of metabolism.Ovid: Blueprints Psychiatry Figure 14-2 • The action of benzodiazepine. such as diazepam. Potency The high-potency benzodiazepines alprazolam and clonazepam are used in the treatment of panic disorder. the major inhibitory neurotransmitter in the forebrain.older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics. the particular combination of the previously mentioned factors (and perhaps as yet unknown variations in affinity for receptor subtypes) produces varied clinical indications for different benzodiazepines.94 CHOICE OF MEDICATION The selection of a benzodiazepine should be based on an understanding of potency. The fast-onset benzodiazepines flurazepam and triazolam are commonly used for insomnia.) P..

toxicology screens may remain positive for several days after the last dose of a long-acting benzodiazepine. oxazepam. Because the oxidative functions of the liver are impaired with liver disease (e.htm (7 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ . all but three drugs metabolized by conjugation (lorazepam. Medications with shorter elimination half-lives are useful for conditions such as insomnia because they are less likely to produce residual daytime sedation or grogginess.. cirrhosis) or with a general decline in liver function (e.. For example. Tolerance and dependence can emerge even after several weeks of file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C. No routine monitoring is required. toxicity can easily occur with repetitive dosing.g. and temazepam. THERAPEUTIC MONITORING Benzodiazepine dosing is generally titrated to maximize symptom relief while minimizing side effects and the potential for abuse. Drugs with longer elimination half-lives offer less likelihood of interdose symptom rebound. they are not of great clinical use. oxazepam. aging). benzodiazepines that require oxidation are more likely to accumulate to toxic levels in individuals with impaired liver function. with the exception of lorazepam. They cannot be discontinued abruptly because of the risk of a withdrawal syndrome that may include seizures.. clonazepam is now favored over alprazolam in the treatment of panic because its longer elimination half-life provides better interdose control of panic symptoms.Ovid: Blueprints Psychiatry All benzodiazepines listed. Elimination Half-Life The elimination half-life depicts the effective duration of action of the metabolized medications. although serum drug levels can be obtained. Care must be taken in prescribing benzodiazepines because of their ability to cause physiologic dependence. In addition..older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics. Active Metabolites Medications with active metabolites generally have a longer elimination half-life.g. require oxidation as a step in their metabolism. For medications with long elimination half-lives. Among the benzodiazepines. temazepam) and clonazepam have active metabolites.

. In healthy individuals. The primary side effect of benzodiazepines is sleepiness or a general groggy feeling.older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics. Use in the elderly must be performed with extreme caution.e. elderly individuals). SIDE EFFECTS AND ADVERSE DRUG REACTIONS The major side effects of benzodiazepines are related to the CNS. P. Benzodiazepines are minimally depressive to the respiratory system in healthy individuals but can lead to fatal carbon dioxide retention in patients with chronic obstructive pulmonary disease..htm (8 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ . Although benzodiazepines are often used to treat agitation. death after overdose on benzodiazepines alone is rare but does occur when benzodiazepines are taken with alcohol and other CNS depressant medications.95 ▪ TABLE 14-2 Frequently Used Benzodiazepines file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C. Long-acting benzodiazepines in the elderly have also been associated with higher rates of motor vehicle accidents.. as benzodiazepines have been shown to increase the risk of falls resulting in large bone fracture. Long-term use of benzodiazepines leads to cognitive impairment that may not completely resolve after discontinuation (this is still under active study). they may produce disinhibition (and therefore worsen agitation) in some patients (i.Ovid: Blueprints Psychiatry use.

5-5 No Yes Yes No No No Yes Panic..0-4.0-100.0-30.0 2. anxiety Anxiety.htm (9 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ . catatonia Alcohol detoxification Insomnia Insomnia a Single-dose equivalency.96 BUSPIRONE (BUSPAR) Indications Buspirone is used primarily for generalized anxiety disorder.0-40.0 7. Because of its long lag time to therapeutic effect. anxiety Alcohol detoxification 0.0-4.0 7.0-120.0 4.0 30.0-30.125-0.0 15.Ovid: Blueprints Psychiatry Oral Dosage Drug Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Diazepam (Valium) Flurazepam (Dalmane) Lorazepam (Ativan) Oxazepam (Serax) Temazepam (Restoril) Triazolam (Halcion) 1 20 120 4 60 60-120 1 Equivalency (mg)a 2 40-100 Single Dosage (mg) 0.5-2.0 Usual Therapeutic Dosage (mg/day) 1.0-25.0-30. Elimination half-life includes all active metabolites.0 0.25 1. P.125-0.older/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics..0 5.0-10.5-2. Buspirone is favored as a treatment in individuals with a history of substance file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20C.0 0.0 15.5-15. b In hours. patients with severe anxiety symptoms may be unable to sustain a clinical trial.5 Intermediate Fast Fast Intermediate Slow Intermediate Fast Oxidation Oxidation Oxidation Conjugation Conjugation Conjugation Oxidation 18-50 30-100 50-160 10-20 8-12 8-20 1.0 Onset Intermediate Intermediate Metabolism Oxidation Oxidation Elimination Half-Lifeb 6-20 30-100 Active Metabolite Yes Yes Common Uses in Psychiatry Panic.0-6.5-30.25-1. insomnia Insomnia Anxiety.0 0.0 1.0 15.0 10.

Mechanism of Action Buspirone is a novel medication that appears to act as an anxiolytic via its action as an agonist at the serotonergic 5HT1A receptor. In addition. sleepiness. The major side effects are dizziness. KEY POINTS ● file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20. it has some D2 antagonist effects. although with unclear clinical significance.. Therapeutic Monitoring No routine monitoring or drug levels are required when using buspirone. In general. It is not a sedative and is not useful in treating insomnia. buspirone lacks the reliability of benzodiazepines in relieving anxiety but can be effective in some people. nor does it produce a significant withdrawal syndrome or dependence.htm (10 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry or benzodiazepine abuse. Side Effects and Adverse Drug Reactions Buspirone does not tend to cause sedation. a period of several weeks of sustained dosing is required to obtain symptomatic relief.lder/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics. it does not work rapidly. Unlike the benzodiazepines.. and nausea. nervousness. Buspirone has no GABA receptor affinity and is therefore not useful in treating benzodiazepine or alcohol withdrawal.

and insomnia.htm (11 of 11) [30/01/2009 06:22:30 ‫]ﻡ‬ .. agitation. file:///C|/Documents%20and%20Settings/ASUS/My%20Documents/My%20.lder/Blueprints%20Psychiatry/Chapter%2014%20-%20Anxiolytics. buspirone binds to serotonin receptors and takes effect after weeks of daily usage. ● Benzodiazepines produce physiologic dependence and may manifest a significant withdrawal syndrome. including anxiolysis.. alcohol detoxification. ● Benzodiazepines have a wide variety of uses. ● Benzodiazepines cause cognitive impairment in all users and also increase the risk of falls and motor vehicle accidents in elderly users. ● Buspirone treats only generalized anxiety and does not cause physiologic dependence. ● Benzodiazepines bind to GABA-A receptors and have a comparatively rapid onset of action.Ovid: Blueprints Psychiatry Anxiolytics include benzodiazepines and buspirone.

Miscellaneous Medications Chapter 15 Miscellaneous Medications This chapter includes medications that are used to treat substance dependence. Title: Blueprints Psychiatry. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 15 . they have a few specific uses. constipation.g. thyroid hormones. as well as medicines commonly used in psychiatric practice that do not fall into the conventional categories of psychotherapeutic drugs.. caused by peripheral anticholinergic action. The most commonly used anticholinergics are benztropine and trihexyphenidyl. Cowan. an antihistamine that also possesses anticholinergic properties. Many medications used in general medical practice have side effects such as sedation. and other drugs. Side effects of anticholinergics. is frequently used to treat neuroleptic-induced movement disorders and to provide nonspecific sedation. β-blockers.. have precise indications for psychiatric usage.. insomnia. or anxiolysis. β-BLOCKERS β-blockers are used widely in general medicine. and Alzheimer's disease. anergia). their principal central side effects are sedation and delirium. diphenhydramine. Anticholinergics are generally used as first-line agents in the treatment of neuroleptic-induced Parkinsonism and for acute dystonia. In psychiatry. ANTICHOLINERGICS Medications with anticholinergic activity are commonly used in psychiatry to treat or provide prophylaxis for some types of neuroleptic-induced movement disorders.r%2015%20-%20Miscellaneous%20Medications. anticholinergics. These side effects are often exploited in psychiatry to target specific symptoms (e. and urinary retention. Ronald L. include blurry vision (as a result of cycloplegia). β-blockers likely alter behavior and file:///C|/Documents%20and%20Settings/ASUS/M. In addition. such as psychostimulants.htm (1 of 7) [30/01/2009 06:22:34 ‫]ﻡ‬ . These medications are central nervous system (CNS) muscarinic antagonists. especially in individuals with dementia and human immunodeficiency virus encephalopathy. Many more medications than are discussed here are included in the psychiatric armamentarium. Other drugs. Table 15-1 shows common indications of psychostimulants. they may also have some utility in treating akathisia but are best tried after β-blockers and lorazepam. attention-deficit hyperactivity disorder (ADHD).. Anticholinergic toxicity is a major cause of delirium. stimulation.Ovid: Blueprints Psychiatry Authors: Murphy. Michael J.

and hyperventilation. Similar medications are approved in other countries for treating depression. asthma exacerbation. they may diminish central arousal. in anxiety. hypotension.. MEDICATIONS USED TO TREAT ADHD ATOMOXETINE Atomoxetine (Strattera) is a selective norepinephrine reuptake inhibitor medicine approved for treating attention-deficit disorder.g. atomoxetine has been associated with an increased risk of suicide in children and adolescents and requires careful monitoring. its efficacy is unknown. Like other medications that have monoamine reuptake as a primary mechanism of action (e.. β-blockers may also produce depression-like syndromes characterized by fatigue and depressed mood.98 States for treating depression. they may reduce tachycardia.htm (2 of 7) [30/01/2009 06:22:34 ‫]ﻡ‬ .r%2015%20-%20Miscellaneous%20Medications. and although atomoxetine is used off-label in the United P. selective serotonin reuptake inhibitors).Ovid: Blueprints Psychiatry mood states by altering both central and peripheral catecholamine function. Common side effects of β-blockers include bradycardia.. and masked hypoglycemia in diabetics. peripherally. especially during the initiation or tapering of therapy. ▪ TABLE 15-1 Psychiatric Uses of Miscellaneous Medications Medication Class Psychostimulants Major Psychiatric Uses Treatment of attention-deficit disorder Treatment of depression in elderly or medically ill Treatment of narcolepsy Augmentation of antidepressants in refractory depression Anticholinergics Treatment of neuroleptic-induced Parkinsonism Treatment of neuroleptic-induced dystonia β-blockers Treatment of impulsivity Treatment of performance anxiety Treatment of akathisia Treatment of lithium-induced tremor Disulfiram Opioid antagonist Prevention of alcohol ingestion Treatment of alcoholism file:///C|/Documents%20and%20Settings/ASUS/M. For example. sweating. tremor.

. Weight loss may be an unwanted side effect in young children but a desirable one in overweight adults. The primary use of clonidine in medicine is as an antihypertensive (Table 15-1). P. dizziness. The α-2 adrenoreceptor is a presynaptic autoreceptor that inhibits the release of CNS norepinephrine. In psychiatry. It is effective in decreasing autonomic symptoms associated with opiate withdrawal. and diaphoresis. The side effects of these medications are due largely to their sympathomimetic actions and include tachycardia. Commonly used psychostimulants are dextroamphetamine (Dexedrine). Psychostimulants have the liabilities of inducing tolerance and psychological dependence. The mechanism of action of these medications appears to occur through their alterations of CNS monoamine function. narcolepsy. Their primary mechanism of action is thought to be facilitating endogenous neurotransmitter release (rather than acting as a direct agonist).htm (3 of 7) [30/01/2009 06:22:34 ‫]ﻡ‬ .r%2015%20-%20Miscellaneous%20Medications. hypertension. in the treatment of ADHD and Tourette's syndrome. Side effects include sedation.Ovid: Blueprints Psychiatry Glutamate modulator Opioid partial agonist Clonidine Treatment of alcoholism Treatment of opiate dependence Treatment of impulsivity Treatment of Tourette's syndrome Treatment of opiate withdrawal Treatment of attention-deficit disorder Acetylcholinesterase inhibitors N-methyl-D-aspartate antagonist Thyroid hormones Treatment of mild-to-moderate memory loss in Alzheimer's disease Treatment of moderate to severe memory loss in Alzheimer's disease Augmentation of antidepressants in refractory depression CLONIDINE Clonidine is a CNS α-2 adrenoreceptor agonist. clonidine has been variously used.. MEDICATIONS USED TO TREAT SUBSTANCE DEPENDENCE file:///C|/Documents%20and%20Settings/ASUS/M. and hypotension. and may be useful for impulsiveness and other forms of behavioral dyscontrol. Adderall (a mixture of amphetamines). insomnia. PSYCHOSTIMULANTS Psychostimulants are used in psychiatry to treat attention-deficit disorder.99 which may lead to abuse. and pemoline (Cylert). methylphenidate (Ritalin). anxiety. and some forms of depression.

making an individual who ingests alcohol while taking disulfiram severely ill within 5 to 10 minutes. As a partial opioid agonist. dyspnea. are available for use in outpatient office-based practices. This medication seems to reduce the craving and urge to drink in patients recently withdrawn from alcohol and helps maintain abstinence and make relapse less severe. Because buprenorphine is a partial opioid agonist. ACAMPROSATE Acamprosate (Campral) is the most recently approved medication used in the treatment of alcohol dependence. hypotension. including as a modulator of glutamate function. vomiting. For individuals coabusing opiates or who are receiving opiates for medical reasons.. a step in the metabolism of alcohol. Fatal reactions. buprenorphine has a role in opiate detoxification. headache. and reduces the severity of a relapse when one occurs.r%2015%20-%20Miscellaneous%20Medications. Disulfiram blocks the oxidation of acetaldehyde. The buildup of acetaldehyde produces a toxic reaction. works best when combined with psychosocial interventions. and confusion occur. Symptoms include flushing. Side effects in the absence of alcohol ingestion include hepatitis. oral buprenorphine (Subutex). Unlike methadone maintenance treatment for opiate dependence (which can only be used in specialized methadone treatment centers). and impotence. DISULFIRAM Disulfiram (Antabuse) is used to prevent alcohol ingestion through the fear of the consequences of ingesting alcohol while taking disulfiram (Table 15-1). and dizziness.htm (4 of 7) [30/01/2009 06:22:34 ‫]ﻡ‬ . chest pain. The parental form of buprenorphine (Buprenex) is used intramuscularly for treating symptoms of opiate withdrawal in some circumstances. can occur. Acamprosate should be combined with psychosocial interventions in the treatment of alcoholism. dry mouth. Acamprosate may work via numerous mechanisms.Ovid: Blueprints Psychiatry NALTREXONE Naltrexone (ReVia) is a µ-opioid antagonist that is used to prevent alcohol relapse and to lessen the severity of a relapse in individuals with alcohol dependence. it has a file:///C|/Documents%20and%20Settings/ASUS/M. although rare. BUPRENORPHINE Buprenorphine is used for the treatment of opiate addiction. Naltrexone. nausea. sweating. Naltrexone treatment is initiated once a patient has been detoxified from alcohol. like all treatments for alcohol dependence. Disulfiram use should be restricted to carefully selected patients who are highly motivated and who fully understand the consequences of drinking alcohol while taking disulfiram.. Naltrexone reduces alcohol craving. or a formulation containing buprenorphine and naloxone (Suboxone). optic neuritis. naltrexone treatment should not be initiated until at least 1 week after the last opiate exposure (an opiate antagonist can precipitate severe opiate withdrawal if given to opiate-dependent persons). reduces the probability of an alcohol relapse. In more severe reactions. Acamprosate is indicated for maintaining abstinence in previously alcohol-dependent subjects who are abstinent at treatment initiation.

Rivastigmine also inhibits butyrylcholinesterase.. ramelteon (Rozerem). 15-1). A new medication. Common side effects include gastrointestinal upset and other cholinomimetic effects including bradycardia and increased gastric acid secretion. and tacrine (Cognex) are reversible inhibitors of the enzyme acetylcholinesterase and are used to enhance cognition in patients with mild-to-moderate dementia of the Alzheimer's type.. and sleep architecture during their use is abnormal. and increasing overall sleep time. however.g. decreasing number and duration of nocturnal awakenings. the naloxone (an opiate antagonist) in the medication has poor absorption and therefore does not interfere with the desired therapeutic effect of buprenorphine. galantamine (Reminyl).htm (5 of 7) [30/01/2009 06:22:34 ‫]ﻡ‬ . If taken as an oral sublingual preparation as prescribed. If the oral pill is crushed or otherwise converted to an injectable form. this effect wanes with the progressive loss of cholinergic neurons. which results in a deficiency of cholinergic neurotransmission (Fig. zaleplon (Sonata). There are also non-benzodiazepine hypnotics: zolpidem (Ambien. The γ-aminobutyric acid modulator sleep aids have been associated with the formation of tolerance and dependence..Ovid: Blueprints Psychiatry greater safety margin with regard to side effects such as respiratory depression. MEDICATIONS USED TO TREAT DEMENTIA (COGNITIVE ENHANCERS) A number of medications are available in the United States for the treatment of cognitive dysfunction associated with Alzheimer's disease. is believed to work by binding to melatonin receptors in the suprachiasmatic nucleus. Mixing buprenorphine with naloxone is designed to prevent diversion of the buprenorphine tablets for recreational intravenous injection. the naloxone component (as a µ-opioid antagonist) is effective. These drugs are γ-aminobutyric acid receptor modulators. By inhibiting the enzyme or enzymes that hydrolyze synaptic acetylcholine. these drugs reduce cognitive impairment. Tacrine can cause elevations in serum transaminases and severe hepatotoxicity and is file:///C|/Documents%20and%20Settings/ASUS/M. Initially.100 medications develops rapidly. these drugs are thought to raise synaptic concentrations of acetylcholine in the remaining cholinergic neurons. a property that may contribute greater efficacy to rivastigmine in later stages of Alzheimer's disease.r%2015%20-%20Miscellaneous%20Medications. rivastigmine (Exelon). and eszopiclone (Lunesta). amytriptiline) and trazadone have been used to treat insomnia. Galantamine also has activity at nicotinic cholinergic receptors that may be clinically significant. Donepezil (Aricept). Naturally occurring melatonin in a pill form is also used to induce sleep. however. Ambien-CR). blocking naloxone's effects as a partial agonist at the µ-opioid receptor. Ramelteon may not have this problem. but further experience and studies are needed to be certain. Some of the cognitive deficits in Alzheimer's disease result from loss of cholinergic neurons in the basal forebrain that project to the cerebral cortex and hippocampus. They do not appear to promote tolerance and dependence but may not promote physiologically normal sleep. Tolerance to these P. Some sedating tricyclic antidepressants (e. MEDICATIONS USED TO TREAT INSOMNIA Most benzodiazepines (see Chapter 14) have hypnotic (sleep-inducing) properties including decreasing sleep-onset latency (time to go to sleep).

htm (6 of 7) [30/01/2009 06:22:35 ‫]ﻡ‬ .) MEMANTINE (NAMENDA) A new class of cognitive enhancers for Alzheimer's disease is available. Antagonism of the N-methyl-D-aspartate receptor may help prevent glutamate-mediated excitotoxicity and improve function of neurons involved in some forms of memory (e. the hippocampus). Figure 15-1 • The cholinergic diffuse modulatory systems arising from the basal forebrain and brain stem.... (Reproduced with permission from Bear MF. Neuroscience: Exploring the Brain. 2001. 2nd Ed. Connors BW.r%2015%20-%20Miscellaneous%20Medications. THYROID HORMONES Thyroid hormones are used primarily in psychiatry to augment the effects of antidepressants. Parasido MA. Philadelphia: Lippincott Williams & Wilkins. Memantine is approved for the treatment of moderate-to-severe dementia of the Alzheimer type. Memantine is an antagonist at the excitatory glutamatergic N-methyl-D-aspartate receptor.Ovid: Blueprints Psychiatry therefore reserved for second-line treatment. They may also be used as adjuncts in file:///C|/Documents%20and%20Settings/ASUS/M.g.

Although clinical hypothyroidism can mimic the symptoms of depression. some individuals without clinical hypothyroidism may respond to thyroid P. and substance dependence.. file:///C|/Documents%20and%20Settings/ASUS/M. symptoms of hyperthyroidism emerge.. ● Medications that affect various neurotransmitters can be used to counteract the side effects of other psychotropic medications. KEY POINTS ● A number of medications are available to treat Alzheimer's disease. both triiodo thyronine and tetra-iodo thyronine cross the blood-brain barrier. The theoretic basis for using thyroid hormones lies in the finding of altered hypothalamic-pituitary-adrenal axis functioning in depressed individuals. when dosages result in overreplacement. Tetra-iodo thyronine has been shown to be of use in conjunction with lithium to improve clinical control of rapid-cycling bipolar disorder.Ovid: Blueprints Psychiatry treating rapid cycling bipolar disorder.htm (7 of 7) [30/01/2009 06:22:35 ‫]ﻡ‬ .101 augmentation. These drugs target brain chemistry believed to be related to the disorder's underlying pathophysiology. ADHD. insomnia. Side effects at low doses are minimal. Although there is debate as to their relative efficacy.r%2015%20-%20Miscellaneous%20Medications.

Major Adverse Drug Reactions Chapter 16 Major Adverse Drug Reactions This chapter describes a group of major adverse reactions associated with use of psychiatric medications. neuroleptic malignant syndrome (NMS). Although the Diagnostic and Statistical Manual of Mental Disorders. Minor adverse reactions and side effects are outlined in the chapters on the respective medications.Ovid: Blueprints Psychiatry Authors: Murphy. Title: Blueprints Psychiatry. and treatment are outlined in Table 16-1. Ronald L. The muscle spasms may lead to abnormal posturing of the head and neck with jaw muscle spasm. classifies dystonia.. extrapyramidal symptoms (EPS).. and tardive dyskinesia as neuroleptic-induced movement disorders. akathisia. they may occur in response to other medications. Cowan.. DYSTONIA Dystonia is a neuroleptic-induced movement disorder characterized by muscle spasms. Michael J. Although the adverse drug reactions discussed below (with the exception of serotonin syndrome) are most commonly produced by antipsychotic medications. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 16 . their risk factors. Symptoms may range from a mild subjective sensation of increased muscle tension to a life-threatening syndrome of severe muscle tetany and laryngeal dystonia (laryngospasm) with airway compromise. Spasm of the tongue leads to macroglossia and dysarthria. onset. The major adverse drug reactions to antipsychotics.htm (1 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ . 4th edition. Dystonia commonly involves the musculature of the head and neck but may also include the extremities and trunk.0-%20Major%20Adverse%20Drug%20Reactions. it is clear that akathisia can occur with the use of nonneuroleptic psychiatric medications. pharyngeal file:///C|/Documents%20and%20Settings/ASUS/.

Most commonly.Ovid: Blueprints Psychiatry dystonia may produce impaired swallowing and drooling.0-%20Major%20Adverse%20Drug%20Reactions. drive them to become assaultive or to attempt suicide.htm (2 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ . ▪ TABLE 16-1 Neuroleptic-Induced Movement Disordersa file:///C|/Documents%20and%20Settings/ASUS/. if unrecognized. intravenous anticholinergic medication is used. Akathisia can produce severe dysphoria and anxiety in patients and may. it is seen shortly after the initiation of an antipsychotic medication. with young men at increased risk. the muscle spasms are mild and respond to oral doses of anticholinergic medication. particularly in a young male patient. is also caused by serotonin reuptake inhibitors. It is important to diagnose akathisia accurately because if mistaken for agitation or worsening psychosis. If laryngospasm is present. in other cases. a common side effect produced by antipsychotic medications. Ocular muscle dystonia may produce oculogyric crisis. antipsychotic P. unable to sit still. They may pace or move about. Akathisia consists of a subjective sensation of inner restlessness or a strong desire to move one's body. Some cases may require intubation if respiratory distress is severe. Individuals with akathisia may appear anxious or agitated. In more severe cases. Risk factors include use of high-potency antipsychotics... Treatment of dystonia depends on the severity of the symptoms. intramuscular anticholinergic medication (benztropine or diphenhydramine) can be used. AKATHISIA Akathisia.103 dosage may be increased with resultant worsening of the akathisia. Discontinuation of the precipitating antipsychotic is sometimes necessary. the addition of anticholinergic medications on a standing basis prevents the recurrence of dystonia. The condition usually develops early in drug therapy (within days). Most commonly.

lorazepam (maybe anticholinergics) EPS High-potency antipsychotics Elderly Prior episode of EPS First few weeks of therapy Anticholinergics Lowering antipsychotic dosage or changing to lower-potency antipsychotic NMS High-dose antipsychotics. dehydration Prior episode of NMS Usually within the first few Discontinuing antipsychotic weeks.Ovid: Blueprints Psychiatry Disorder Dystonia Risk Factors High-potency antipsychotics Young men Onset First few days of therapy Treatment IM/IV benztropine or diphenhydramine Severe laryngospasm may require intubation Akathisia Recent increase/onset of medication dosing First month of therapy Propanolol.htm (3 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ .. or IM injection of antipsychotics Agitation. rapid-dose escalation. can occur at any point medication in antipsychotic therapy Supportive symptom management Dantrolene. bromocriptine May require intensive care Usually after years of treatment Lowering dosage of antipsychotic Changing antipsychotics Changing to Clozaril TD Elderly Long-term antipsychotic treatment Female African American Mood disorders file:///C|/Documents%20and%20Settings/ASUS/..0-%20Major%20Adverse%20Drug%20Reactions.

htm (4 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ . EPS. intravenous. A 3. and Clozaril.Ovid: Blueprints Psychiatry aThe DSM-IV classification for these disorders defines them as neuroleptic-induced movement disorders. NMS. anticholinergics (diphenhydramine or benztropine) are also used frequently. EPS EPS. EPS. neuroleptic malignant syndrome. The most common symptoms are rigidity and akinesia. Akinesia or bradykinesia are manifested by decreased spontaneous movement and may be accompanied by drooling. which does not appear to produce dystonia. Risk factors for akathisia include a recent increase in medication dosing or the recent onset of medication use. which occur in as many as half of all patients receiving long-term neuroleptic therapy. Exceptions include risperdone. The term neuroleptic generally refers to typical antipsychotics (see Chapter 11). Treatment consists of reducing the medication (if possible) or using either β-blockers (propanolol is commonly used) or benzodiazepines (especially lorazepam). IM. selective serotonin-reuptake inhibitors.to 6-Hz tremor may be present in the head and face muscles or the limbs. intramuscular.. Although there is some debate regarding their efficacy. Most cases occur within the first month of drug therapy but can occur at any time during treatment. which is classified as an atypical antipsychotic but can cause all the above disorders. akathisia. Tardive dyskinesia. or TD but may cause NMS.0-%20Major%20Adverse%20Drug%20Reactions. IV.. increasing age. which are not neuroleptic drugs but can clearly produce akathisia. Rigidity consists of the classic Parkinsonian “lead pipe” rigidity (rigidity that is present continuously throughout the passive movement of an extremity) or cogwheel rigidity (rigidity with a catch-and-release character). also known as neuroleptic-induced Parkinsonism. and a prior file:///C|/Documents%20and%20Settings/ASUS/. consist of the development of the classic symptoms of Parkinson's disease in response to neuroleptic use. TD. extrapyramidal symptoms. Risk factors for the development of EPS include the use of high-potency neuroleptics.

Symptoms of NMS may develop gradually over a period of hours to days and can often overlap with symptoms of general medical illness. for example.0-%20Major%20Adverse%20Drug%20Reactions. rapid dose file:///C|/Documents%20and%20Settings/ASUS/. The diagnosis of NMS is also complicated by the waxing and waning nature of the clinical picture. although this does occur with NMS. Mutism can be a sign of severe psychosis or catatonia alone. Behavioral features such as agitation can also overlap with other psychiatric syndromes. the presence of delirium or seizures is a harbinger of more serious general medical illness (including drug withdrawal) or NMS. however. Low-grade fever progressing to severe hyperthermia may also be present. rigidity/dystonia can be confused with simple dystonia or with EPS. Motor findings may overlap with other motor abnormalities in psychiatric illness.. Risk factors for the development of NMS (Table 16-1) include the use of high-dose antipsychotics.htm (5 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ .. in response to any medication that blocks dopamine receptors and in response to reductions or changes in dopamine agonist medications.Ovid: Blueprints Psychiatry episode of EPS. Laboratory findings may reveal an increased creatine kinase secondary to myonecrosis from sustained muscular rigidity. Autonomic instability coupled with motor abnormalities is essential to the diagnosis of NMS. P.104 NMS NMS is an idiosyncratic and potentially life-threatening complication most commonly associated with antipsychotic drug use. NMS may occur spontaneously. but their relation to NMS is unclear. EPS usually develops within the first few weeks of therapy. The major clinical findings in patients with NMS are presented in Table 16-2. Liver enzymes may be elevated. Leukocytosis is also often present. Many symptoms of NMS are nonspecific and overlap with symptoms common to other psychiatric and medical conditions. however. Treatment consists of reducing the dosage of antipsychotic (if possible) and adding anticholinergic medications to the regimen. Autonomic alterations can include cardiovascular alterations with cardiac arrhythmias and labile blood pressure.

Symptoms of NMS overlap with serotonin syndrome (Table 16-3). dehydration.htm (6 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ .. agitation. and require intramuscular injection of an antipsychotic) rather than causative factors.g. restoration of recently withdrawn dopamine agonists. Although NMS is most common during the first few weeks of antipsychotic drug therapy. the diagnosis can be quite difficult. muscular rigidity and increased creatine kinase are prominent. or a prior history of NMS. ▪ TABLE 16-2 Neuroleptic Malignant Syndrome Autonomic Tachycardia... Treatment of this potentially fatal disorder is largely supportive. Symptom management including intensive care with cardiac monitoring and intubation may be necessary. other cardiac arrhythmias Hypertension Hypotension Diaphoresis file:///C|/Documents%20and%20Settings/ASUS/.g. and bromocriptine (a dopamine agonist) is sometimes used to reverse dopamine-blocking effects of antipsychotics. severely ill patients often have poor oral intake and become dehydrated. In addition. Specific interventions include discontinuation of antipsychotics (an option that may take a long period of time in individuals treated with depot antipsychotics). it can occur at any time during therapy.0-%20Major%20Adverse%20Drug%20Reactions. dantrolene (a muscle relaxant) is used to decrease rigidity and myonecrosis.Ovid: Blueprints Psychiatry escalation. however. in NMS. are more likely to be placed in restraints. In patients using both MAOIs and antipsychotics (e. Some factors may be related to severity of illness (e.. intramuscular injection of antipsychotics. whereas NMS develops in response to antidopaminergic medications. serotonin syndrome develops in response to the use of medications that affect serotonin function (especially monoamine oxidase inhibitors [MAOIs]). refractory psychotic depression).

.htm (7 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ .105 ▪ TABLE 16-3 Serotonin Syndrome file:///C|/Documents%20and%20Settings/ASUS/.Ovid: Blueprints Psychiatry Fever progressing to hyperthermia Motor Rigidity/dystonia Akinesia Mutism Dysphagia Behavioral Agitation Incontinence Delirium Seizures Coma Laboratory Increased creatine kinase Abnormal liver function tests Increased white blood cell count P.0-%20Major%20Adverse%20Drug%20Reactions..

.0-%20Major%20Adverse%20Drug%20Reactions. TD consists of constant. the extremities and respiratory and oropharyngeal musculature are also involved.Ovid: Blueprints Psychiatry Autonomic Tachycardia Hypertension Diaphoresis Fever progressing to hyperthermia Motor Shivering Myoclonus Tremor Hyperreflexia Ocolumotor abnormalities Behavioral Restlessness Agitation Delirium Coma TARDIVE DYSKINESIA Tardive dyskinesia (TD) is a movement disorder that develops with long-term neuroleptic use. and the presence of a file:///C|/Documents%20and%20Settings/ASUS/. rarely. stereotyped choreoathetoid (dance-like) movements most frequently confined to the head and neck musculature. it occurs spontaneously in elderly individuals who have not taken antipsychotic medications. Risk factors include long-term treatment with neuroleptics. At times. female gender. increasing age.htm (8 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ . involuntary..

are not known. lowering the dosage.g.. and behavioral changes. Treatment for serotonin syndrome is largely supportive and may require intensive care with cardiac P. Serotonin syndrome may present with shivering. consists of symptoms outlined in Table 16-3. Serotonin syndrome has many similarities to NMS. Treatment consists of changing antipsychotics. Muscular rigidity can develop in severe cases of serotonin syndrome. A similar syndrome occurs when MAOIs are used with meperidine or dextromethorphan and perhaps other opiates.htm (9 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ . it tends to be permanent. other than combining MAOIs with other serotonin-altering medications. Although TD is reversible in some cases. while serotonin syndrome can be abrupt. whereas serotonin syndrome occurs through use of MAOIs or other serotonergic agents. Prominent gastrointestinal symptoms (e. motor abnormalities. These include severe autonomic instability.Ovid: Blueprints Psychiatry mood disorder. or switching to clozapine. Risk factors for serotonin syndrome. and clonus.. which can be life threatening. may reduce or eliminate the abnormal movements of TD.0-%20Major%20Adverse%20Drug%20Reactions. NMS tends to have a gradual onset. hyperreflexia. nausea and diarrhea) may suggest serotonin syndrome.. This syndrome. The course of the disorder can exist on a continuum from very mild symptoms to becoming malignant and ending in coma and death. thus mimicking NMS. this syndrome is produced when other serotonin-altering medications are used with MAOIs. which appears to work by a mechanism different from other antipsychotics. NMS occurs following or during the use of antipsychotic medication. but clues to the differential diagnosis may arise from the history of medication exposure and the clinical symptoms. Classically.106 file:///C|/Documents%20and%20Settings/ASUS/. SEROTONIN SYNDROME Serotonin syndrome results from high synaptic concentrations of serotonin. Clozapine. The syndrome can result from a single use of medications or illicit drugs that are serotonergically active but most commonly occurs when multiple medications that alter serotonin metabolism are used simultaneously (Table 16-4).

The serotonin 2A receptor antagonist cyproheptadine shows efficacy in treating this condition. The mechanisms underlying the weight gain and glucose dysregulation are unclear.. The most problematic agents in this regard are olanzapine and clozapine. The offending medications should be discontinued.0-%20Major%20Adverse%20Drug%20Reactions. ▪ TABLE 16-4 Serotonergically Active Agents Buspirone Citalopram Clomipramine Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline Trazadone Venlafaxine 3.. although all atypical antipsychotics and some mood stabilizers (lithium and valproic acid) are associated with increased body mass and may precipitate diabetes.htm (10 of 11) [30/01/2009 06:22:39 ‫]ﻡ‬ . insulin resistance. sometimes file:///C|/Documents%20and%20Settings/ASUS/. and hyperlipidemia).Ovid: Blueprints Psychiatry monitoring and mechanical ventilation.4-methylenedioxy-methamphetamine (Ecstasy) METABOLIC EFFECTS Many psychotropic agents appear to affect energy balance in the body. Some antipsychotics also appear to increase appetite. leading to weight gain and potentially the metabolic syndrome (obesity. Antipsychotics are typically used in patients who have psychosis and who are also less physically active because of the illness.

NMS. or diabetes. ● Antipsychotics can cause dystonia. except for TD.. Patients and their involved families should be informed of the risks prior to therapy initiation.0-%20Major%20Adverse%20Drug%20Reactions. ● Serotonin-altering medications can cause akathisia and serotonin syndrome. the benefits of antipsychotic therapy for psychotic disorders outweigh the risks of metabolic effects. Antipsychotics also may decrease metabolism (although this is not proven). Baseline body measurements and fasting lipids and glucose should be checked at initiation and periodically during treatment. EPS. akathisia. file:///C|/Documents%20and%20Settings/ASUS/. ● All of the above adverse drug reactions are reversible though treatment.htm (11 of 11) [30/01/2009 06:22:40 ‫]ﻡ‬ . which may be permanent.Ovid: Blueprints Psychiatry substantially. TD and weight gain. KEY POINTS ● Major adverse drug reactions occur most commonly in psychiatry with the use of antipsychotics and serotonin-altering medications. Generally. Medication choices should be made based on a thoughtful calculation of the risks and the benefits of the therapy in question..

Ovid: Blueprints Psychiatry Authors: Murphy. Title: Blueprints Psychiatry. cognitive-behavioral interventions...htm (1 of 10) [30/01/2009 06:22:44 ‫]ﻡ‬ .. file:///C|/Documents%20and%20Settings/ASUS/M. and object relations theory. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 17 . Ronald L. TWENTIETH-CENTURY SCHOOLS OF PSYCHODYNAMIC PSYCHOLOGY There are three major 20th-century psychodynamic schools: drive psychology.Psychological Theory and Psychotherapy Chapter 17 Psychological Theory and Psychotherapy There are a large number of competing theories influencing contemporary psychotherapeutic thinking.hological%20Theory%20and%20Psychotherapy. Freud's theories proposed that unconscious motivations and early developmental influences were essential to understanding behavior. and interpersonal therapy have the strongest empirical verification. ego psychology. Short-term psychodynamic therapy. Freud's original theories have proved quite controversial and have led to the creation of various alternative or derivative theories subsumed by three major schools of psychodynamic thinking. cognitive. Cowan. little empirical evidence supports the efficacy of analytic/dynamic therapies. and behavioral theories are the most widely used. PSYCHOLOGICAL THEORIES PSYCHOANALYTIC/PSYCHODYNAMIC THEORY The principal theorist responsible for launching psychoanalysis as a technique and psychodynamic theory in general is Sigmund Freud. Psychotherapies derived from psychoanalytic. Michael J.

The superego contains the sense of right and wrong... emphasizing concepts of attachment and separation. largely derived from parental and societal morality.. The ego is responsible for adaptation to the environment and for the resolution of conflict.g. phallic. This theory proposes that sexual and aggressive instincts are present in each individual and that each individual passes sequentially through psychosexual developmental stages (oral. file:///C|/Documents%20and%20Settings/ASUS/M.hological%20Theory%20and%20Psychotherapy.Ovid: Blueprints Psychiatry Drive Psychology Drive psychology posits that infants have sexual (and other) drives. Ego Psychology Freud eventually developed a tripartite theory of the mind in which the psychic structure was composed of the id.htm (2 of 10) [30/01/2009 06:22:44 ‫]ﻡ‬ . Ego defenses (Table 17-1) are proposed as psychic mechanisms that protect the ego from anxiety. Under this theory. and superego. latency. which proposes to explain how character and personality development are influenced by the interaction of drives with the conscience and reality.108 primacy of the relationship rather than the object being a means of satisfying a drive. and genital).. Object Relations Theory Object relations theory (objects refers to important people in one's life) departs from drive theory in that the relationship to an object is motivated by the P. A major function of the ego is the reduction of anxiety. Some ego defenses (e. Child observation furthered object relations theory. sublimation) are more functional for the individual than others (e. the id is the compartment of the mind containing the drives and instincts. ego. anal. Included in drive psychology is conflict theory. denial).g.

Feelings or ideas that are distressing to the ego are converted into their opposites. leading to a developmental crisis. Erikson theorized that ego development persists throughout one's life and conceptualized that psychosocial events drive change. Rationalization Feelings or ideas that are distressing to the ego are dealt with by creating an acceptable alternative explanation. Feelings or ideas that are distressing to the ego are redirected to a substitute that evokes a less intense emotional response.Ovid: Blueprints Psychiatry ▪ TABLE 17-1 Common Ego Defense Mechanisms Denial Feelings or ideas that are distressing to the ego are blocked by refusing to recognize evidence for their existence. Individual progress and associated ego development occur with successful resolution of the developmental crisis inherent in file:///C|/Documents%20and%20Settings/ASUS/M.. individuals pass through a series of life cycle stages (Table 17-2). Repression Reaction formation Displacement Feelings or ideas that are distressing to the ego are relegated to the unconscious. Feelings or ideas that are distressing to the ego are reduced by behavioral return to an earlier development phase.htm (3 of 10) [30/01/2009 06:22:44 ‫]ﻡ‬ .hological%20Theory%20and%20Psychotherapy. Each stage presents core conflicts produced by the interaction of developmental possibility with the external world.. but they remain components of conscious awareness. Sublimation Feelings or ideas that are distressing to the ego are converted to those that are more acceptable. According to Erikson's model. Projection Regression Feelings or ideas that are distressing to the ego are attributed to others. Suppression Feelings or ideas that are distressing to the ego are not dealt with. DEVELOPMENTAL THEORY Erik Erikson made major contributions to the concept of ego development.

BEHAVIORAL THEORY Behavioral theory posits that behaviors are fashioned through various forms of learning. including modeling. A behaviorist might propose that. PSYCHOTHERAPIES SHORT-TERM PSYCHODYNAMIC PSYCHOTHERAPY file:///C|/Documents%20and%20Settings/ASUS/M. alcohol dependence. resulting in a general lack of interest in behaviors that were once pleasurable (or reinforced). classical conditioning. paraphilias. thoughts or cognitions regarding an experience determine the emotions that are evoked by the experience. COGNITIVE THEORY Cognitive theory recognizes the importance of the subjective experience of oneself.htm (4 of 10) [30/01/2009 06:22:44 ‫]ﻡ‬ . the world..hological%20Theory%20and%20Psychotherapy. others. and the world. the perception of danger in a situation naturally leads to anxiety.Ovid: Blueprints Psychiatry each stage. A principal type of irrational belief is a cognitive distortion (Table 17-3). Table 17-5 lists common behavioral therapy techniques. Behavior therapy may be useful for agoraphobia.. For example. When the situation is only perceived as dangerous (such as in fear of public speaking). the resulting anxiety can be psychologically paralyzing. This model allows for continued ego development until death. It posits that irrational beliefs and thoughts about oneself. Behavior includes observable actions (not mental states) and can thus be directly observed and measured. A person may fear public speaking because of an irrational fear that something disastrous will occur in public. phobias. leading to hypervigilance and self-protection. depression is caused by a lack of positive reinforcement (as may occur after the death of a spouse). and sexual dysfunction. psychotic conditions. When danger is truly present. through operant conditioning. and operant conditioning (Table 17-4). anxiety can be adaptive. eating disorders. and one's future can lead to psychopathology. In cognitive theory.

If inappropriate or inadequate. is broadly effective for improving quality of social function. manual-based. recurrent themes in one's life. systematic therapy that employs psychodynamic principles to treat psychiatric conditions. If caretaking is appropriate. The therapy is usually less than 40 sessions P. The child is dependent on caretakers. identified target symptoms. but individual patients may well show a superior response to one form of therapy over another. ▪ TABLE 17-2 Erikson's Life Cycle Stages Trust vs mistrust Birth-18 mo The infant has many needs but does not have the power to have those needs met. and general psychiatric symptoms.. mistrust develops.Ovid: Blueprints Psychiatry Short-term psychodynamic psychotherapy is a modern. If caretaking is appropriate.. Effects persist well beyond the treatment period. Autonomy vs shame 18 mo-3 y The child is learning about the use of language and control of bowel and bladder function and walking. Short-term psychodynamic therapy appears to be generally comparable to cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (ITP) (information to follow) in efficacy. dreams. Conflicts and themes are the target of treatment and may encompass patterns of behavior or feeling.e. he or she begins to choose to influence and explore the world.. when properly applied by well-trained therapists. Short-term psychodynamic psychotherapy. As a result. a sense of trust and hope are created. the child will develop a healthy balance between exerting his or her autonomy and feeling shame over the consequences of exerting autonomy. and attention to wishes. file:///C|/Documents%20and%20Settings/ASUS/M. early childhood and past events are not the focus).hological%20Theory%20and%20Psychotherapy.109 and has a focus on the present (i.htm (5 of 10) [30/01/2009 06:22:45 ‫]ﻡ‬ . and fantasies.

Industry vs inferiority 5-13 y The child begins to develop a sense of self based on the things he or she creates. There are conflicts between one's identity and the need to gain acceptance. If unsuccessful.. 7th Ed. 1999. Identity vs confusion 13-31 y Corresponds to adolescence. ▪ TABLE 17-3 Types of Cognitive Distortions file:///C|/Documents%20and%20Settings/ASUS/M. Comprehensive Textbook of Psychiatry. the individual may regret or wish to relive some part of life. How one appears to others is important in this stage. Philadelphia: Lippincott Williams & Wilkins. leading to despair.htm (6 of 10) [30/01/2009 06:22:45 ‫]ﻡ‬ . individuals move through life without concern for the greater welfare. the individual develops a positive view of his or her role in life and a sense of commitment to society at large.Ovid: Blueprints Psychiatry Initiative vs guilt 3-5 y As the child develops increasing control of language and walking. Modified from Sadock BJ.. Generativity vs stagnation 40-60 y If successful. Ego integrity vs despair 60 y-death An individual accepts his or her life course as appropriate and necessary. Sadock VA. he or she has increased initiative to explore the world. If this fails. The potential for action carries with it the risk of guilt at indulging forbidden wishes. Caretaker influences are important in helping the child develop a sense of mastery and competence over creating. Intimacy vs isolation 21-40 y The anxiety and vulnerability produced by intimacy are balanced against the loneliness produced by isolation.hological%20Theory%20and%20Psychotherapy.

the relationships in a person's life are given primary importance in producing happiness or misery. IPT The interpersonal school arose as an outgrowth of object relations theory. In other words.. Philadelphia: Lippincott Williams & Wilkins. Comprehensive Textbook of Psychiatry.or undervaluing the significance of a particular event Modified from Sadock BJ.htm (7 of 10) [30/01/2009 06:22:45 ‫]ﻡ‬ . 1999.Ovid: Blueprints Psychiatry Arbitrary inference Dichotomous thinking Overgeneralization Magnification/minimization Drawing a specific conclusion without sufficient evidence A tendency to categorize experience as “all or none” Forming and applying a general conclusion based on an isolated event Over. with the result that the previously neutral stimulus alone becomes capable of eliciting the same response as the natural stimulus Operant conditioning A form of learning in which environmental events (contingencies) influence the acquisition of new behaviors or the extinction of existing behaviors. 7th Ed.110 ▪ TABLE 17-4 Important Concepts in Behavior Theory Modeling Classical conditioning A form of learning based on observing others and imitating their actions and responses A form of learning in which a neutral stimulus is repetitively paired with a natural stimulus. P.hological%20Theory%20and%20Psychotherapy.. The interpersonal theorists emphasize that intrapsychic conflicts are less important than one's relationship to one's sense of self and to others. IPT for depression and related conditions has good empirical validation and may work as well as medication treatment and possibly file:///C|/Documents%20and%20Settings/ASUS/M. Sadock VA.

Synopsis of Psychiatry. Participant modeling Patients view others and imitate behaviors of others (e. ▪ TABLE 17-5 Common Behavioral Therapy Techniques Systematic desensitization Patient approaches an anxiety-provoking stimulus after entering a relaxed state.g. CBT has strong empirical file:///C|/Documents%20and%20Settings/ASUS/M.htm (8 of 10) [30/01/2009 06:22:45 ‫]ﻡ‬ . often in graded fashion. Positive reinforcement Social skills training Patients are provided a rewarding stimulus after engaging in a specific behavior.. 10th Ed. Therapeutic graded exposure Patient approaches anxiety-provoking stimulus in a graded fashion (but does not enter relaxed state prior to stimulus exposure). CBT Cognitive and behavioral theories form part of the bases of CBT. Aversion therapy Patients are provided noxious stimuli (e. watching another person approach an anxiety-provoking stimulus). CBT involves the examination of cognitive distortions and the use of behavioral techniques to treat common disorders such as major depression. Baltimore: Lippincott Williams & Wilkins. Based on Sadock BJ.g. Assertiveness training Patient is trained to monitor and modify responses to circumstances requiring acting in patient's best interests... Sadock VA. Flooding Patient approaches/is exposed to anxiety-provoking stimulus without using a graded approach..hological%20Theory%20and%20Psychotherapy. electric shocks) after engaging in a specific behavior. Patients lacking social skills in specific dimensions systematically monitor and rehearse behavioral social skills.Ovid: Blueprints Psychiatry better than CBT when interpersonal themes are prominent.

. but those derived from psychoanalytic. DIALECTICAL-BEHAVIORAL THERAPY Dialectical behavioral therapy (DBT) is a psychotherapy developed specifically for the treatment P. Overall. social phobia.htm (9 of 10) [30/01/2009 06:22:45 ‫]ﻡ‬ . CBT and pharmacotherapy. The foundation of DBT resides in CBT principles. such as antidepressant medications. particularly with regard to the treatment of depression.hological%20Theory%20and%20Psychotherapy. are generally thought to be synergistic. KEY POINTS ● Psychological theories are numerous. Zen philosophy. obsessive-compulsive disorder. but the therapy encompasses empirical findings from multiple areas of psychology. file:///C|/Documents%20and%20Settings/ASUS/M. CBT as a treatment..Ovid: Blueprints Psychiatry validation and is effective in the treatment of depression. cognitive. and behavioral theories are most widely used. sociology.111 of borderline personality disorder in females. appears to have long-lasting effects in terms of preventing relapse that have not been well demonstrated with medication treatment for most conditions. and panic disorder. however. DBT has strong empirical support in the treatment of borderline personality disorder and is the first-line psychotherapy for treating this condition. DBT focuses on therapist and patient acceptance of the patient as the foundation for developing skills for behavioral and emotional change. and dialectical philosophy. posttraumatic stress disorder. ● The psychoanalytic school emphasizes unconscious motivations and early influences.

● Brief psychodynamic psychotherapy has empirical support for general efficacy across a range of psychiatric conditions.htm (10 of 10) [30/01/2009 06:22:45 ‫]ﻡ‬ . ● CBT and IPT have the greatest empirical support for treating depression and anxiety. beliefs. ● The behavioral school emphasizes the influence of learning. ● The cognitive school emphasizes subjective experience. file:///C|/Documents%20and%20Settings/ASUS/.ological%20Theory%20and%20Psychotherapy...Ovid: Blueprints Psychiatry ● The object relations school emphasizes the importance of relationships with other people. and thoughts.

appropriate levels of information regarding a proposed treatment. Malpractice claims in psychiatry principally involve suicides of patients in treatment. MALPRACTICE The legal definition of malpractice requires the presence of four elements: negligence. negligence.. INFORMED CONSENT Informed consent has three elements: information. Second. Previous court decisions. and damages. physical or emotional harm) must in fact be shown to have occurred. medication complications. capacity. consent. Practitioners should be aware of the pertinent laws of the state in which they practice in order to comply adequately with standards of practice while respecting the rights and duties of their role. as well as patient competence or capacity. the patient must have capacity. possess the ability to understand. reason. and express a choice (make decisions) regarding the risks and benefits of treatment.htm (1 of 4) [30/01/2009 06:22:47 ‫]ﻡ‬ .. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Table of Contents > Chapter 18 .. that is. Having capacity requires more than simply repeating information and necessitates that a person demonstrate comprehension and flexible manipulation of the information in file:///C|/Documents%20and%20Settings/ASUS/M. Ronald L. Title: Blueprints Psychiatry. First.Ovid: Blueprints Psychiatry Authors: Murphy.g. or precedents. false imprisonment (involuntary hospitalization or seclusion). alternative treatments. Direct causation requires that the negligence directly caused the alleged damages. This definition of duty of care requires the presence of a doctor-patient relationship. and sexual relations with patients. malpractice involves the negligence of a duty that directly causes damages. Finally. falling short of the care that would be provided by the average practitioner (the standard of care). and right to refuse treatment. and malpractice. must be provided (the process of informing or disclosing). The laws that govern medical practice address physician duty. and outcome without treatment.Legal Issues Chapter 18 Legal Issues Legal issues affect all areas of medicine. damages (e. and consent. In short.hiatry/Chapter%2018%20-%20Legal%20Issues. Reducing adverse events and legal claims in the health care system is known as risk management. including side effects. misdiagnosis. including psychiatry. are used as the standard by which a given action (or inaction) is judged. Michael J. appreciate. Cowan.. duty. Negligence can be thought of as failure to perform some task with respect to the patient. Duty reflects the law's recognition of the physician's obligation to provide proper care to his or her patients. direct causation.

temporarily and involuntarily. if any of these criteria are met and a diagnosis of a mental disorder is provided (in other words. or schizophrenia P. Figure 18-1 • The elements of informed consent and capacity. the patient must give consent voluntarily (important to the concept of volition is the lack of subtle or overt coercion). and unless they have been declared incompetent.Ovid: Blueprints Psychiatry the context of a specific decision.113 may still retain capacity to consent to treatment or research interventions. mild dementia.. they have the right to refuse treatment. the word capacity is used to describe a patient or research volunteer's ability to make a treatment or research participation decision. The two terms are often used interchangeably. treatments necessary to stabilize a patient in an emergency can be given without informed consent. True emergency situations are an exception to this rule.) It is important to realize that individuals who have psychiatric disorders such as major depression. or is unable to care for him or herself. Patients who have been committed have a right to be treated. All that is required is that a person meets the aforementioned criteria for capacity.hiatry/Chapter%2018%20-%20Legal%20Issues. both a mental disorder and danger must exist). Competence generally refers to the findings of a judicial or other legal proceeding regarding a person's ability to consent. The elements of informed consent and capacity are depicted in Figure 18-1. INVOLUNTARY COMMITMENT Commitments are generally judicially supported actions that require persons to be hospitalized or treated against their will. Although laws vary from state to state. The duration of temporary commitment and the rights of the patient vary by jurisdiction. have the right to commit a patient.htm (2 of 4) [30/01/2009 06:22:47 ‫]ﻡ‬ . in most localities. commitment criteria usually require evidence that the patient is a danger to self. Third. THE TARASOFF DECISIONS: DUTY TO WARN (OR PROTECT) file:///C|/Documents%20and%20Settings/ASUS/M. however. (Commonly.. a danger to others. Psychiatrists.

● The Tarasoff decision led to an expectation that therapists and doctors take reasonable action to protect persons whom their patients have specifically threatened. KEY POINTS ● Malpractice consists of negligence. altering treatment. and consent. Protection may be defined by specific state law or prevailing legal interpretation. it is important to understand the requirements of each jurisdiction. direct causation. M'NAGHTEN RULE: THE INSANITY DEFENSE Named after a mentally ill man (Daniel M'Naghten) who attempted to assassinate the prime minister of England in 1843. In most localities. Tarasoff) was a landmark case that was heard twice in the California Supreme Court. however.. duty. etc. notifying the police. the appropriate use of the insanity defense has been called into question. a person is not held responsible for a criminal act if at the time of the act he or she suffered from mental illness or mental retardation and did not understand the nature of the act or realize that it was wrong. Tarasoff II (1982 ruling) held that therapists have a duty to take reasonable steps to protect potential victims of their patients. capacity. Because the specific legal requirements vary by state law. Such varying interpretations of physicians' responsibilities regarding the balance between confidentiality and protecting others create great difficulty in psychiatric practice. but it may include hospitalizing the patient. There are many different legal interpretations. and damages. warning the intended victim or victims.htm (3 of 4) [30/01/2009 06:22:47 ‫]ﻡ‬ . ● The essential elements of informed consent are information. Some legal theorists argue for the designation “guilty but insane” to indicate culpability but at the same time recognize the presence of a mental illness (and presumably the need for treatment). According to the M'Naghten rule. this means that the therapist should take reasonable action to protect a third party if a patient has specifically identified the third party and a risk of serious harm seems imminent. In more recent history. of the duty to warn. ● file:///C|/Documents%20and%20Settings/ASUS/M.hiatry/Chapter%2018%20-%20Legal%20Issues. this rule forms the basis of the insanity defense..Ovid: Blueprints Psychiatry Tarasoff v The Board of Regents of the University of California (or simply. Tarasoff I (1976 ruling) held that therapists have a duty to warn the potential victims of their patients.

file:///C|/Documents%20and%20Settings/ASUS/M...Ovid: Blueprints Psychiatry The M'Naghten rule is the basis of the insanity defense.hiatry/Chapter%2018%20-%20Legal%20Issues.htm (4 of 4) [30/01/2009 06:22:47 ‫]ﻡ‬ .

you note that his lipid profile was within normal limits. You find that total cholesterol is elevated at 262.htm (1 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . you see him in your outpatient psychiatry clinic for routine follow-up.Substance-Related are elevated at 250.Eating Disorders b.Preface . Diabetes insipidus [+] Chapter 6 . Which other medical condition is the patient at risk of developing? Disorders a.Psychotic Disorders [+] Chapter 2 . and HDL cholesterol is low at 20. You weigh the patient and request laboratory tests. LDL cholesterol is elevated at 180. He was admitted to the inpatient psychiatry ward and started on the atypical antipsychotic olanzapine. One month later.Anxiety Disorders [+] Chapter 4 . Prior to the patient's psychiatric hospitalization.Ovid: Ovid: Blueprints Psychiatry Browse BooksMain Search PageDisplay Knowledge BaseHelpLogoff Books@Ovid Title Search TOC View Copyright Statement | Purchase Print Copy Blueprints Psychiatry > Back of Book > Questions Search: Current Book All Books Check Spelling Front of Book ↑ Back Save | Print Preview | Email | Email Jumpstart [+] Authors .Acknowledgments [+] Abbreviations ↑ Questions 1. He reports that his psychiatric symptoms are under good management but complains that he has gained 10 pounds in weight since discharge from the hospital.. triglycerides Table of Contents [+] Chapter 1 .Personality Disorders [+] Chapter 5 .Mood Disorders [+] Chapter 3 .Blueprints%20Psychiatry/Questions%20-%201.. Cataracts file:///C|/Documents%20and%20Settings/ASUS/My. An 18-year-old male has been newly diagnosed with schizophrenia.

Anxiolytics [+] Chapter 15 . he began complaining of nausea. She reports that 3 to 4 days ago. The laboratory studies sent from the outside hospital do not indicate any gross abnormalities. A 58-year-old man is transferred to your psychiatric facility after medical stabilization at an outside hospital. vomiting. What was the most likely cause of this man's generalized Medications [+] Chapter 16 .Blueprints%20Psychiatry/Questions%20-%201.Cognitive Disorders e. she found him in his room unresponsive with jerking movements of his arms and legs. Sedative-hypnotic withdrawal Back of Book d.” She reports he takes a lot of medications but had to Somatic Therapies [+] Chapter 13 . Yesterday.Legal Issues ↑ c.htm (2 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . Alcohol withdrawal file:///C|/Documents%20and%20Settings/ASUS/My.Miscellaneous Disorders View Answer [+] Chapter 10 . Acute stroke [+] Chapter 17 .Mood Stabilizers [+] Chapter 14 . and feeling weak. The patient gives you permission to speak with his adult daughter who can provide information about the events leading Settings [+] Chapter 11 .Miscellaneous stop his “nerve medication” about a week ago because his insurance would no longer pay for it. Leukopenia [+] Chapter 9 . She cannot recall the name of the medication.Major Adverse Drug seizure? Reactions a. Diabetes mellitus Childhood and Adolescence d. The daughter reports that her father has diabetes. sweating. heart problems.Antidepressants and up to the hospitalization.Disorders of c..Ovid: Ovid: Blueprints Psychiatry [+] Chapter 7 .Special Clinical 2. Nonketotic hyperglycemia [+] Chapter 18 ..Antipsychotics [+] Chapter 12 .Psychological Theory and Psychotherapy b. Hyponatremia [+] References e. and “bad nerves. Hypothyroidism [+] Chapter 8 .

but she has never sought treatment. A 39-year-old patient tells you that he believes his mother has been mentally ill for many years.Ovid: Ovid: Blueprints Psychiatry . Persecutory View Answer 4. Erotomanic e. She says he seems preoccupied and has started to go days file:///C|/Documents%20and%20Settings/ASUS/My. His mother reports that she also noticed he stopped socializing with friends and began spending more time alone in his room.. Her belief that this man was in love with her would be categorized as what type of delusion? A G N T B H O U C I P V D K Q W E L R Z a. he called the police. His mother reports that she has been trying to home school him.Blueprints%20Psychiatry/Questions%20-%201. Jealous c. Somatic d. He began doing so poorly at school that he dropped out earlier this year. A 17-year-old male is brought to your office by his mother for an evaluation. In taking his history. After a couple months.Questions . He tells you about an incident F M S when his mother became convinced that the new neighbor who moved in across the street was in love with her. but she began to follow him around and spy on him.. but he does not seem interested in learning. Grandiose b. you discover that he had always been a good student until age 15 when his grades began dropping.htm (3 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . She had never spoken to the man.Answers [-] Index View Answer 3. and she was found guilty of stalking in a court of law.

Substance abuse disorder c. Damages file:///C|/Documents%20and%20Settings/ASUS/My. What is his most likely diagnosis? a.. Direct causation c.. You are asked to review the case. Which of the following elements is evidenced by this physician's unfamiliarity with the diagnosis? a. Brief psychotic disorder e.118 d. On questioning. and the diagnosis has only been well established for the past 5 years. A physician is very attentive and compassionate with his patients. Major depressive disorder b. His mother decided to bring him to see a psychiatrist because for the last 2 months.Blueprints%20Psychiatry/Questions%20-%201.Ovid: Ovid: Blueprints Psychiatry without bathing. Schizophreniform View Answer 5. One of his patients sustains a permanent injury that would not have occurred if the physician had made the correct diagnosis. the physician is unaware of the diagnosis. He does not seem to care about his appearance. Schizophrenia P. she has overheard him having what sounds like conversations with someone in his room despite being alone. Duty b.htm (4 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . The physician finished his residency more than 20 years ago.

Which of the following agents would be an appropriate choice to address this new problem? a. Benztropine c.. Pemoline d. On examination. Vital signs are stable but for sinus tachycardia of 100 beats per minute. you note that the file:///C|/Documents%20and%20Settings/ASUS/My. the patient appears acutely distressed. Atenolol e.. but he is complaining of some muscular rigidity. While on call. Failure to meet standard of care e. A 20-year-old man with schizophrenia has recently had a change in his antipsychotic medication. Poor risk management View Answer 6. You are the psychiatry resident on the inpatient psychotic disorders unit of a busy teaching hospital.htm (5 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . he is looking upward. Briefly reviewing his chart. His delusions and hallucinations are now well controlled. Methylphenidate b. you are asked to urgently assess a 32-year-old African American male patient who was admitted 2 days ago in an agitated state following an altercation with his mother. and is unable to follow your finger when you attempt to test his eye movements.Ovid: Ovid: Blueprints Psychiatry d.Blueprints%20Psychiatry/Questions%20-%201. Clonidine View Answer 7.

the patient has received up to three 5-mg doses of haloperidol per day for acute agitation since admission. Cholinesterase inhibitor e. has no prior history of treatment with psychotropic medications. She has been evaluated by an orthopaedic surgeon.. and head. and has recently been started on scheduled haloperidol 5 mg by mouth twice per day. Anticholinergic agent c.. No abnormalities were detected on neurologic evaluation. Conversion disorder file:///C|/Documents%20and%20Settings/ASUS/My. This presentation is most consistent with which of the following? a. knees. She has recently completed a workup for a seizure disorder. α-2 adrenergic antagonist b. She reports that she has been unable to attain orgasm for several years. She has been followed in a pain clinic for management of pain in her neck.htm (6 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ .Blueprints%20Psychiatry/Questions%20-%201.Ovid: Ovid: Blueprints Psychiatry patient has been diagnosed with psychotic disorder not otherwise specified. but no underlying etiology could be identified. β-adrenergic antagonist d. In addition. Somatization disorder b. lower back. Selective serotonin reuptake inhibitor View Answer 8. Coadministering haloperidol with which of the following classes of medication might have prevented this reaction? a. She further reports a long history of difficulty swallowing and numerous dietary restrictions. A 26-year-old woman presents with multiple complaints.

. Stage 2 c. her air conditioner quit working during the summertime. Stage 0 b. He appears awake and intensely frightened but then falls back asleep and has no memory of the event. Delta d. Stage 1 View Answer 10.htm (7 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . She was recently switched to a new antipsychotic medication with rapid dosage titration by her outpatient psychiatrist. This disturbance most likely occurs during what phase of sleep? a. Pain disorder d. Hypochondriasis e. The parents report that they have witnessed the child sit up in bed with a frightened expression and scream loudly.. A 50-year-old single female patient with schizoaffective disorder lives independently in an apartment with the assistance of case management services. Body dysmorphic disorder View Answer 9. A 5-year-old boy is brought to your office because of problems sleeping. when the maximum ambient temperature was file:///C|/Documents%20and%20Settings/ASUS/My.Ovid: Ovid: Blueprints Psychiatry c.Blueprints%20Psychiatry/Questions%20-%201. A few days later. REM e.

LDL cholesterol e. Creatine kinase b. which of the following laboratory values was most likely to be grossly elevated? a. sweating.htm (8 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . angrily stating that he file:///C|/Documents%20and%20Settings/ASUS/My. The patient refuses medication. Although the patient opened her eyes when the case manager shook her gently.. During the patient's subsequent hospitalization in the ICU. INR P.Blueprints%20Psychiatry/Questions%20-%201. When you assess him in your capacity as the on-call attending psychiatrist. she did not respond to any questions.119 d. Glucose c. The case manager let herself into the apartment when the patient failed to answer the door and was shocked to find the patient lying face down on the living room floor.. The patient's case manager paid her a home visit after the patient failed to answer the telephone. A 45-year-old male patient with a long history of schizophrenia is involuntarily committed to the state psychiatric hospital because he is experiencing command auditory hallucinations urging him to kill his mother. who he believes is an agent of the devil.Ovid: Ovid: Blueprints Psychiatry approximately 101°F. The patient appeared febrile. and the case manager telephoned immediately for an ambulance. Platelet count View Answer 11. you recommend a treatment plan in which you suggest starting back on an antipsychotic medication. and rigid.

The cardiac monitor shows that she is in pulseless electrical activity. Magnesium c. Communicating a choice c. Calcium b. you notice that she is mildly obese.. As you work to resuscitate her. A reduced plasma level of which of the following electrolytes is likely to have led to this patient's cardiac arrest? a. You are working as the ER resident in a large tertiary referral center. Which of the following aspects of capacity is the patient unable to demonstrate? a. Deciding on a choice d. Reasoning about treatment options e. Understanding the information you have communicated View Answer 12.Ovid: Ovid: Blueprints Psychiatry does not have a mental illness. has dry skin. Sodium file:///C|/Documents%20and%20Settings/ASUS/My. Phosphate d.Blueprints%20Psychiatry/Questions%20-%201. Appreciating the nature of his illness b. and a positive Russell's sign (callus on the back of her hand).. swollen parotid glands.htm (9 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . Potassium e. Emergency medical personnel bring a young female patient in cardiac arrest to the ER.

A 45-year-old woman presents with a 1-year history of the following symptoms: sweating. The symptoms develop over about 10 minutes in situations where she feels trapped. The patient indicates that she would prefer to avoid treatment with medications if at all possible. Family therapy e.Ovid: Ovid: Blueprints Psychiatry View Answer 13. You are an outpatient psychiatrist practicing at the student health center of a small college campus. which of the following psychotherapeutic modalities has the greatest evidence base? a. A 24-year-old female student presents to your office complaining of the recent onset of low mood and poor concentration. trembling. Exposure therapy d. lightheadedness. After completing a history and physical and ordering appropriate laboratory work. mild.lueprints%20Psychiatry/Questions%20-%201. derealization. chest discomfort.. The patient has been largely disabled by the symptoms. In determining her treatment plan. Cognitive behavioral therapy b. single episode. She has been unable to pick up her children at file:///C|/Documents%20and%20Settings/ASUS/M. you diagnose her with major depressive disorder. sensation of choking. Dialectical behavioral therapy c.. precipitated by increasing difficulty in managing her college courses. Long-term psychodynamic psychotherapy View Answer 14.htm (10 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . fear of losing control. and fear of dying.

Biofeedback therapy d. Classical conditioning View Answer 15. She has been reading about the disorder and has some familiarity with its pharmacologic management. go shopping. You begin by teaching relaxation exercises and desensitization combined with education aimed at helping the patient understand that her panic attacks are the result of misinterpreting bodily sensations.htm (11 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . The patient described in Question 14 becomes impatient with the progress of her psychotherapy. Psychodynamic therapy c. Which of the following medications meet these criteria? a. She now requests psychopharmacologic management.. Mirtazapine c. Imipramine d. Alprazolam b..lueprints%20Psychiatry/Questions%20-%201. What is the name of this technique? a. Cognitive-behavioral therapy e. Paroxetine file:///C|/Documents%20and%20Settings/ASUS/M. Exposure therapy b.Ovid: Ovid: Blueprints Psychiatry school. Of the appropriate medications. or engage in her normal social events. you choose a medication that acts as an agonist at the GABA receptor. She would like to avoid using any type of medication.

Ovid: Ovid: Blueprints Psychiatry e. Some of the cognitive deficits in Alzheimer's disease are caused by loss of cholinergic neurons in the basal forebrain that project to the cerebral cortex and hippocampus.htm (12 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . The electrocardiogram demonstrates a flattening of the T waves with development of U waves. Hypokalemia b..120 the effectiveness of acetylcholine transmission in the remaining neurons. What is the mechanism by which donepezil and tacrine achieve this? file:///C|/Documents%20and%20Settings/ASUS/M.lueprints%20Psychiatry/Questions%20-%201. Hypercalcemia d. She has been treated with sertraline and states that she has been taking it as prescribed.. What is the most likely finding? a. Hyperkalemia c. One of the current mainstays of therapy is to increase P. Esophageal rupture View Answer 17. Phenelzine View Answer 16. A 22-year-old woman with a prior diagnosis of bulimia nervosa presents to the emergency room during her college exam period with an irregular heartbeat. Hypocalcemia e. On examination. the patient is noted to have a callus on the second joint of the right index finger. The patient is weighed and found to be at her ideal weight.

Ovid: Ovid: Blueprints Psychiatry a. A basic electrolyte laboratory panel reveals a serum sodium of 119 mmol/L. Presynaptically blocking reuptake of acetylcholine d. glycopyrrolate (Robinul) 2 mg qhs.. Her blood pressure is elevated at 195/95 mm Hg. She does not smoke. Acting as a postsynaptic agonist View Answer 18.htm (13 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . Clozapine toxicity c. Her medicines include clozapine 500 mg qhs. She is lethargic and disoriented upon arrival and gradually becomes more alert during your assessment. Her chest radiograph is normal. What is the most likely diagnosis? a. and escitalopram 20 mg qd. A staff member from the group home tells you that the patient has been under stress lately and has been drinking a large amount of diet cola..lueprints%20Psychiatry/Questions%20-%201. A 48-year-old woman who lives in a state-supported group home presents to the emergency department after having a witnessed grand mal seizure shortly after dinner. Her heart rate is 90 beats per minute. Syndrome of inappropriate antidiuretic hormone secretion b. She tells you that she does not remember what happened. Hypertensive encephalopathy file:///C|/Documents%20and%20Settings/ASUS/M. Binding to the acetylcholine postsynaptic receptor b. Reversibly inhibiting acetylcholinesterase e. lithium 500 mg tid. and her respiratory rate is 15 breaths per minute. Irreversibly binding acetylcholinesterase c.

and then she just left and never returned. appetite change or weight loss or gain. She begins to cry and then suddenly gets angry when you ask whether the nurse took her vitals. She says. and her eyes avert to the floor again. and you begin examining her.lueprints%20Psychiatry/Questions%20-%201. impaired concentration or decision making. some of which appear old and some more recent.” You finish her examination and refer her to a colleague for a psychiatric consultation. sleep disturbance. She has numerous scratch marks on her upper thighs. psychomotor agitation or retardation. worthlessness or guilt. you begin to review her medical history. From your recollections from file:///C|/Documents%20and%20Settings/ASUS/M. “It makes the pain bearable.Ovid: Ovid: Blueprints Psychiatry d. You are running late and have kept her waiting for 40 minutes alone in the examination room. “I did them. Primary polydipsia e. thoughts of death or suicide). A 24-year-old woman presents for a routine physical examination. She tells you that her boyfriend of 2 months left her abruptly last month. You ask how she got them. and she endorses some symptoms but not enough to diagnose major depression. She is staring down at the floor when you arrive. Sensing that she is still having difficulties.” she states. you ask her what is going on in her life. fatigue or low energy. You query her about neurovegetative symptoms (such as depressed mood. and she has not been able to stop crying. She clearly brightens in response to your attention to her feelings.htm (14 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ . Apologizing. Serotonin syndrome View Answer 19..” You explain that there are many other patients in your primary care office today and that she had to go and see other patients.. decreased interests or pleasure. “I was having such a nice conversation with her.

Generalized anxiety disorder e. appearing humiliated and then snaps back at you. He arrives for the appointment 15 minutes late and looks annoyed with you.lueprints%20Psychiatry/Questions%20-%201. you suspect she will be diagnosed with: a. He goes on to explain that he has been fired from or left several jobs in the past because his coworkers failed to recognize his unique talents. In each situation. He noticeably calms and then confesses that he really does not file:///C|/Documents%20and%20Settings/ASUS/M.htm (15 of 73) [30/01/2009 06:23:10 ‫]ﻡ‬ ..Ovid: Ovid: Blueprints Psychiatry your own psychiatric training in medical school. “What do you know about business leadership? You're a doctor. Borderline personality disorder d.” You explain that you were curious about the nature of his talents. He is surprised when you ask what qualities he has that he thinks sets him apart. in fact. you could provide such information. Major depression c. he describes feeling as if he could have led the organization better and that. he should be the boss. Narcissistic personality disorder b. Sexual masochism View Answer 20. He blushes a bit. A 45-year-old divorced man is referred to you from his company's employee assistance program because he is on probation at his job. You explain to him that his evaluation is confidential but that if there is information that he would like shared with his employer to help provide accommodations. You are asked to evaluate him for the presence of a mental illness that could be affecting his performance..

You are asked by the nurse at your clinic to conduct a home visit on a reclusive 47-year-old woman who has been unable to come in for an appointment for the last 3 years..” gesturing toward the street.Ovid: Ovid: Blueprints Psychiatry have any talents and begins to cry.lueprints%20Psychiatry/Questions%20-%201. Schizoid personality disorder b. Since then. She shows you into the house where you find the patient sitting in a house dress in a reclining chair in her living room.121 happened 3 years ago. grandiose subtype c. What is the most likely diagnosis? a. Dependent personality disorder View Answer 21. Borderline personality disorder d. Narcissistic personality disorder e. Delusional disorder. she has had many more such attacks. She has refused to leave her home file:///C|/Documents%20and%20Settings/ASUS/M.htm (16 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . She tells you that she has not left the house in 3 years “because it is too scary out there. He denies neurovegetative signs of depression and exhibits no manic signs or symptoms. It lasted approximately 15 minutes but caused her to run out of the mall and back to the safety of her car. You ask more about what P. She recounts that she was out at a shopping center when she suddenly had the abrupt onset of a severe wave of anxiety. You listen and talk some more and then complete your evaluation.. Her daughter agrees to meet you at the home the next morning.

Obsessive-compulsive disorder View Answer 22.. Generalized anxiety disorder d. talking loudly. His mother was unharmed. He was verbally aggressive and pacing.Ovid: Ovid: Blueprints Psychiatry for the last 2 1/2 years. file:///C|/Documents%20and%20Settings/ASUS/M. A 9-year-old boy is brought into the emergency department by his distraught parents after he tried to attack his mother with a kitchen knife. but then his personality began to change. The police escorted them to the emergency department where the boy was restrained and medicated acutely with a combination of emergency sedatives.. She says that she likes having people visit her.lueprints%20Psychiatry/Questions%20-%201. Where before he was an affable. but she just can't bring herself to go out again. Panic disorder c. She asks you if you understand what is going on with her and can you fix it? You tell her that you have seen this before and can recommend the right kinds of treatment. and swearing. She said that the same thing happened to her mother. The parents explain to you that their son seemed to develop attention-deficit disorder a few months ago and was prescribed a dextroamphetamine-containing medication by his pediatrician. but the parents called the police who suggested an emergency evaluation after observing the boy's demeanor. It seemed to help at first. The primary condition is: a. and she spent the rest of her life at home. She has the attacks sometimes at home and has not sought treatment for them. Major depression b. Arachnophobia e.htm (17 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .

When she is at home. Start citalopram therapy b. and his mother had attention-deficit/hyperactivity disorder as a child. Major depression file:///C|/Documents%20and%20Settings/ASUS/M. The best next step would be to hospitalize the patient and: a. Discontinue dextroamphetamine therapy View Answer 23. Start aripiprazole therapy d. When she is at school. Start lithium therapy c.. as she does not reciprocate social interactions with her peers. however. The situation worsened recently when he started accusing his mother of putting poison in his food.htm (18 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . What do you tell the mother her daughter suffers from? a. He attacked his mother after she made a new dish with which he was unfamiliar. She is having difficulty socially. Start group therapy e. and sleepless. Her mother tells you that her daughter talks all the time at home and has many interests and activities. she does not speak spontaneously and will only speak when spoken to directly by her teacher. he became increasingly wary.Ovid: Ovid: Blueprints Psychiatry bright. His maternal uncle has schizophrenia. An 8-year-old girl presents for a pediatric visit because her teacher has raised concerns about her lack of talking at school. athletic boy.. she plays actively with her two sisters and talks normally. The patient's father has bipolar disorder.lueprints%20Psychiatry/Questions%20-%201. She also describes her daughter as having achieved all developmental milestones at appropriate ages. agitated.

A week later. On examination. Posttraumatic stress disorder c. Physostigmine c.. Selective mutism e. make a diagnosis. Autism d. The best emergency treatment for this patient is: a. piloerection. The patient reports that she has previously used oxycodone for her back pain for brief periods but has not used any pain relievers for several months.htm (19 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Naloxone file:///C|/Documents%20and%20Settings/ASUS/M..” You obtain an additional laboratory test. Flumazenil b. the patient is noted to have a runny nose. and prescribe treatment for this patient. Clonidine d. Acamprosate e. dilated pupils. she is unconscious with very slow respirations and mild perioral cyanosis. She states that she has back problems “about twice a year. Abulia View Answer 24. A 27-year-old nurse appears in a private physician's office complaining of recurrent back pain.Ovid: Ovid: Blueprints Psychiatry b. you are the emergency ward attending physician when the patient is brought in by ambulance. and mild tachycardia. mild fever.lueprints%20Psychiatry/Questions%20-%201.

You find him in good physical shape and note that he makes good eye contact with you but appears confused by what you are trying to do. is educable but will need extra support P. Moderate mental retardation View Answer file:///C|/Documents%20and%20Settings/ASUS/M. Alprazolam g.Ovid: Ovid: Blueprints Psychiatry f. Thiamine h. will need institutional care b. He has developed physically but has been slow in his development of language skills and has extreme difficulty following instructions..htm (20 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Glucose View Answer 25. will need special education d. you tell the parents his diagnosis and prognosis. and his parents have been alarmed by his failure to reach developmental milestones. They are: a. Autistic disorder. Upon your next visit.lueprints%20Psychiatry/Questions%20-%201. He also cries and reaches for his mother several times when you are trying to examine him.122 c. You refer him for neuropsychological testing and the results reveal an IQ of 62.. Asperger's syndrome. Mild mental retardation. The child had not started school in his country. A 4-year-old boy whose family recently emigrated from another country is brought in by his parents for an initial visit with the pediatrician. Severe mental retardation. will be able to function with support e.

htm (21 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . you louse!” When you enter the room. You examine her and order a head CT. Before you enter the room. Call the local police to have the daughter arrested e. Refer her back to her primary care physician and send her home View Answer 27. You suspect elder abuse and order a radiograph series looking for other fractures.lueprints%20Psychiatry/Questions%20-%201. He says. She tells you that she fell out of bed and landed on her face.. the next best step is to: a. The head CT reveals a subdural hematoma that appears to be less than a week old. Call the risk management officer for the hospital b. he appears file:///C|/Documents%20and%20Settings/ASUS/M. and after the patient is evaluated.Ovid: Ovid: Blueprints Psychiatry 26. She and her husband both smell of alcohol but do not appear intoxicated. Call the son-in-law at home and confront him d.. You obtain a surgical consult. A 39-year-old woman walks into the emergency department with a broken nose. you check in with her again. “You deserved it this time. you overhear the husband speaking in a threatening tone to his wife. Call social services for a consult c. After consulting a neurosurgeon about the need for subdural drainage. She had been previously doing well until she was left at home with her daughter's husband for a week while the daughter was away on business. An 88-year-old woman is brought into the emergency room by her daughter because of a change in her mental status. There is also soft tissue swelling over her cranium and around her jaw. The radiograph series reveals several recent fractures of the ribs and long bones of her body.

Call the police to arrest the husband b. He has a core temperature of 101°F. and valproic acid.. You order a complete metabolic serum panel. You obtain an old discharge summary from a surgical admission from 2 years ago for appendicitis. fluoxetine. Pull the husband out of the room and confront him c. Dystonia file:///C|/Documents%20and%20Settings/ASUS/M. Call the patient's home to see if anyone there knows what happened e. Serotonin syndrome b. you find mention that the patient was taking olanzapine. In it.000 units per liter. heart rate of 128 beats per minute. The most likely diagnosis is: a. A 28-year-old man from the local state hospital is brought into the emergency department mute and in a rigid posture..lueprints%20Psychiatry/Questions%20-%201. Ask the couple more about how she fell out of the bed View Answer 28. but little else. and responds to deep tissue pain. a blood pressure of 200/110 mm Hg.Ovid: Ovid: Blueprints Psychiatry startled and she appears frightened.htm (22 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . trazodone. is able to move all four extremities distally and proximally. haloperidol. His creatine phosphokinase comes back severely elevated at 110. The best next step would be to: a. His blood pressure becomes unstable. Try to separate the couple and talk to the woman alone d. You suspect spousal abuse. Neuroleptic malignant syndrome c. and you move him to the intensive care unit.

African American race b. Full-time employment d. Further history reveals that his wife died 1 year ago today. A 27-year-old female patient presents to the emergency department complaining of the recent onset of tremor and diarrhea.” You notice that his voice sounds sad and flat. On examination. Male gender e. You are a volunteer manning a mental health crisis hotline. but she recently doubled the dose because it did not seem to be file:///C|/Documents%20and%20Settings/ASUS/M. Pneumonia View Answer 29. Tardive dyskinesia e. Which of the following is a risk factor for suicide? a. Strong religious faith View Answer 30.htm (23 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . She reports that her outpatient psychiatrist started her on a new medication for bipolar disorder 2 weeks ago. you receive a call from an unidentified male located in the rural counties who tells you that he “just needed someone to talk to.lueprints%20Psychiatry/Questions%20-%201.Ovid: Ovid: Blueprints Psychiatry d. Dependent children in the home c. Her gait is ataxic.. she is oriented to place and person but not to time and exhibits impairment in short-term memory.. You proceed to complete a suicide risk assessment. Late one evening. and she exhibits a coarse bilateral tremor.

This medication is most likely to be: a. Folate c. Lamotrigine c. including meeting with an old drinking buddy in the residents' quarters. A homeless man is brought to the emergency department by the police in response to reports that he has been wandering the streets in a confused state.lueprints%20Psychiatry/Questions%20-%201. he is not oriented to time. B12 b. Lithium d. place.. Valproic acid View Answer 31. Niacin P. He does not exhibit nystagmus or ataxia..htm (24 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . On examination. He is very talkative with marked anterograde amnesia and makes a variety of flamboyant and widely varying claims about how he came to be in the emergency department today. This presentation is caused by deficiency of which of the following vitamins? a. On the Mini-Mental state exam. or person.123 file:///C|/Documents%20and%20Settings/ASUS/M. he appears disheveled and smells faintly of alcohol.Ovid: Ovid: Blueprints Psychiatry working. Haloperidol b. Carbamazepine e.

Huntington's disease d.lueprints%20Psychiatry/Questions%20-%201. There is a family history of early-onset dementia. Vascular dementia View Answer 33.. He reports that she has undergone a significant change in personality over the last 12 months. her husband reveals that the other day. Your file:///C|/Documents%20and%20Settings/ASUS/M. Thiamine e. The patient scores 24 out of 30 on Mini-Mental state examination. What is the most likely diagnosis? a. HIV-related dementia c. Pick's disease e.. Previously. A 53-year-old married female presents to your primary care clinic accompanied by her concerned husband. she attempted to masturbate in public. a meticulously groomed woman who was actively involved in church and charity work.htm (25 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Vitamin E View Answer 32.Ovid: Ovid: Blueprints Psychiatry d. prompting the visit to your clinic today. Alzheimer's disease b. she is now exhibiting poor hygiene and disinhibited behavior such as striking her husband when she does “not get her own way. Your laboratory workup is unremarkable.” With significant embarrassment. but MRI of the brain reveals significant atrophy in the frontal and anterior temporal lobes. A 22-year-old man presents to your office pacing and speaking rapidly.

.htm (26 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . The following day. Gabapentin e. Reviewing his vital signs. After gathering more history from his family. On examination. you note that they were within file:///C|/Documents%20and%20Settings/ASUS/M. he jumps up and starts rambling about going to medical school and being especially gifted. He describes no longer needing sleep. you find the patient pacing around his room swearing at the nursing staff and threatening to leave the hospital. Valproic acid View Answer 34. mastering speed reading. you decide that he is acutely manic. A 36-year-old male patient with a history of sedative-hypnotic dependence is admitted to the ICU after being found down at home by his mother with an empty bottle of alprazolam pills at his bedside.lueprints%20Psychiatry/Questions%20-%201. She asks you to see him immediately.Ovid: Ovid: Blueprints Psychiatry nurse tries to get him to calm down and wait for you but is unable. The medication most likely to help his condition is: a.. Acamprosate d. but you note that he appears to be diaphoretic and observe a coarse tremor of his forearms. and you are consulted urgently for assessment of agitation. He asks you what he should wear when he wins the Nobel Prize for medicine. he is extubated. Fluoxetine c. and spending money on expensive clothes for his new career. When you enter the room. He fails to cooperate with your efforts to interview him. He is sedated and intubated by the medical team for agitation and respiratory depression. Flumazenil b.

htm (27 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Although it is 10:00 AM. You are aware that you feel quite uncomfortable in her presence because of her seductiveness. Avoidant c. and is wearing full makeup. and proceeds to tell you all about her vibrant social life in a highly dramatic and overfamiliar manner.Ovid: Ovid: Blueprints Psychiatry normal limits until 2 hours ago. Antisocial b. Phenobarbital e. Methadone d. you notice that she appears to include brief acquaintances such as the mailman among her confidants. Dependent file:///C|/Documents%20and%20Settings/ASUS/M. a tight low-cut pink top. she is dressed in black leather pants. when the patient's pulse increased to 120 beats per minute and his blood pressure increased to 150/100. Clonidine c. Although she reports that she has many friends. Buprenorphine b. Propranolol View Answer 35. A 32-year-old single female presents to your family practice office for an initial visit.. Which of the following medications is the best choice in management of this patient? a. She sits down with ease. You suspect the presence of which of the following personality disorders? a..lueprints%20Psychiatry/Questions%20-%201. leans forward.

He failed to respond when smiled at. she noted that her child did not seem to respond to her attempts to communicate with him. Two days after admission. A 3-year-old boy is evaluated in the pediatric general practice clinic because his mother thinks he's “too quiet. and didn't maintain eye contact. Attention-deficit disorder e. A few months after birth. Childhood-onset schizophrenia c..” She notes specifically that her pregnancy and delivery were uncomplicated. Histrionic e. The most likely diagnosis is: a. Autistic disorder b. A 69-year-old widowed female patient is admitted to the cardiac surgery service after developing an infection of her sternotomy site following a coronary artery bypass graft.lueprints%20Psychiatry/Questions%20-%201.. she worries that he sits for hours rocking back and forth. He doesn't play with other children and overall shows little interest in his external world. Conduct disorder d. In addition. had almost no facial expressions. the nursing staff expresses concern because file:///C|/Documents%20and%20Settings/ASUS/M. He didn't babble or begin talking like other children his age but used only occasional odd-sounding phrases in a repetitive fashion.htm (28 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .Ovid: Ovid: Blueprints Psychiatry d. Schizoid View Answer 36. Separation-anxiety disorder View Answer 37.

. She states that the patient has been saying she would be better off dead and that life isn't worth living. Delirium b. Dementia c. disoriented as to time and place. The primary team urgently consults you in your capacity as the on-call hospital psychiatrist when the patient is observed to be acutely agitated and trying to call the police because she believes that there are burglars in her room. Which of the following is the most likely diagnosis? a. and cannot recall a list of three items at 5 minutes. you find an anxious elderly female who is inattentive to your questions.124 particularly at night.. Major depressive disorder e.lueprints%20Psychiatry/Questions%20-%201.htm (29 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . On assessment. but she believes they let file:///C|/Documents%20and%20Settings/ASUS/M. Dissociative amnesia d.Ovid: Ovid: Blueprints Psychiatry she appears to be intermittently confused. A 48-year-old woman is interviewed in the emergency department after her sister brought her in because she was afraid the patient might “do something crazy.” The sister reports that the patient has been depressed for a very long time and has been undergoing serious stress. She recounts a stressor of losing her job 1 month ago because of cutbacks. The patient reports that she has been progressively more depressed during the past month. P. Schizophrenia View Answer 38.

she learned that her previously rent-controlled apartment where she had lived for many years was being sold and that she would have to move. file:///C|/Documents%20and%20Settings/ASUS/M.lueprints%20Psychiatry/Questions%20-%201. Major depression b. You make the diagnosis of major depression.Ovid: Ovid: Blueprints Psychiatry her go because she wasn't performing well.. Loss of a romantic relationship d. He tells you that he was recently hospitalized for the fourth time in the last year for paranoia. A 24-year-old man with a history of schizoaffective disorder presents in your primary care office with his mother for a routine physical examination. Neurovegetative symptoms c. 3 weeks ago. A week prior to admission. The most important risk factor for suicide in this patient is: a. She loves her neighborhood but won't be able to afford living there any longer. she ended a long-term romantic relationship of 5 years after a great deal of anger and turmoil. In addition.htm (30 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Hopelessness View Answer 39. In addition. Loss of her job e. She is vague when directly questioned about suicidality. but you are concerned about the patient's suicide risk. She notes that she is hopeless about the future and that she doesn't believe she will ever feel better. She reports that she has felt seriously depressed for at least 1 month and has had marked neurovegetative symptoms of depression. she reports a profound sense of anhedonia and spends her days lying in bed without eating or showering..

lueprints%20Psychiatry/Questions%20-%201. His physical examination is normal. Clozapine d.. His mother accompanies him on the visit and relays that she often decides things for him because he has “never been able to think for himself. and a file:///C|/Documents%20and%20Settings/ASUS/M. you notice that his white blood count came back at a low 1.htm (31 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Risperidone b. His father died when he was 14. “People think I'm too clingy. no magical or odd thinking.9. I just want people to care about me. and he has lived with his mother since that time. You counsel him on smoking cessation and order a routine complete blood count. The truth is. A 39-year-old man visits a new primary care physician for a first visit at the urging of his mother.” When you speak with him alone. You ask that the patient be brought into your office for re-evaluation and page his psychiatrist.Ovid: Ovid: Blueprints Psychiatry His psychiatrist started him on a new medication. Quetiapine e. The most likely antipsychotic agent the patient has been taking is: a. Thioridazine View Answer 40. but then the patient forgot his first follow-up appointment.. He works as a computer programmer and says that he has many acquaintances but few friends and no romantic relationships. 2 days later. Then. Aripiprazole c. he appears to have a normal intellect. He denies symptoms of depression except for occasional low mood.” He says. His mother had to convince him to go to the appointment because he had trouble deciding to see a physician.

A 27-year-old woman is brought to the emergency department by the local police because she has been harassing her neighbors. she has seemed increasingly odd.125 file:///C|/Documents%20and%20Settings/ASUS/M. the police found the place to be filthy and malodorous.htm (32 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Narcissistic personality disorder e. The windows were sealed and covered with dark curtains. The most likely diagnosis is: a.Ovid: Ovid: Blueprints Psychiatry stable sense of self but reveals a desperate fear that his mother will abandon him.. On mental status examination.lueprints%20Psychiatry/Questions%20-%201. disassociated herself from family activities. In addition. Dependent personality disorder c. The police report states that the young woman's apartment manager called because she was banging on all her neighbors' doors and screaming in the stairwell. she had abruptly ended a long-term romantic relationship for no particular reason. Her family arrives shortly afterward and appears very concerned. the young woman is disheveled P. He denies any self-destructive or impulsive behaviors. Borderline personality disorder b. and there were several televisions and computers in the living room. Personality disorder View Answer 41. and gave up a well-paying job as a computer system administrator. Upon examining the patient's apartment. The patient's family reports that for the past year or so. all turned on at the same time.. with rotting garbage and food in the kitchen. Schizotypal personality disorder d.

and brain MRI are all normal. including drug screen. The most likely diagnosis is: a. Schizophrenia b. drunk driving. Penal file:///C|/Documents%20and%20Settings/ASUS/M.. She denies hearing voices. complete blood count. She states that she left her job to monitor these hidden transmissions full time and that she has been hiding in her apartment because they know she is on to them. When you ask him about his other criminal history. he relays numerous arrests and some convictions for theft. volume. Alcohol abuse e. Her speech is normal in rate. assault. She believes that she began picking up on hidden transmissions in her e-mail at work. Diagnostic testing. He tells you that he is in jail for murdering two people in a botched robbery attempt. She denies substance use or any medical symptoms.lueprints%20Psychiatry/Questions%20-%201. Major depression d. chemistry panel. and production. She ended her recent relationships because she felt that the aliens would harm the people she cared about. She appears wary and guarded. revealing an alien conspiracy. A 35-year-old man is seen in a prison clinic for a routine physical examination. She is conversant and explains that she has been defending herself against aliens who want to use her as a specimen. Paranoid personality disorder View Answer 42. perhaps involving the CIA. Bipolar disorder c. and rape..Ovid: Ovid: Blueprints Psychiatry and wearing several layers of dirty clothes.htm (33 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . She reports that she has been eating and sleeping well and that her mood is good.

He has had suicidal ideation but has not made suicide attempts or been self-destructive. or psychotic symptoms. He exhibits no grandiosity.lueprints%20Psychiatry/Questions%20-%201. expansive. Conduct disorder b. not otherwise specified and begun on risperidone 1 mg twice per day.. He was knocked unconscious on several occasions but has no history of seizures and denies nightmares or flashbacks from the abuse.htm (34 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . He calmly reports that his father and subsequent foster parents often beat him with straps or boards when he was a child. Family history is significant for alcohol dependence in his father and mother and for no history of bipolar disorder. He was diagnosed with psychotic disorder. A 19-year-old man is seen on rounds on a psychiatric unit after being admitted two nights before. The nurse asked you to see him first because he had been “agitated all morning. Bipolar disorder e. He tells you that he feels restless and that he has to keep file:///C|/Documents%20and%20Settings/ASUS/M.. He has never been psychiatrically hospitalized and denies any episodes of elevated. The most likely diagnosis is: a. Antisocial personality disorder View Answer 43. you find him pacing the floor. Posttraumatic stress disorder c. or fluctuating mood.Ovid: Ovid: Blueprints Psychiatry records indicate a persistent pattern of lying and theft while incarcerated and that he exhibits no remorse when caught by authorities. pressured speech. Cyclothymic disorder d.” When you enter his room.

He states that he develops a powerful urge to bark and yelp and that other times he finds himself moving uncontrollably. This behavior persists in public and at school. do not appear to have worsened since admission.. he has periods of bizarre body posturing with jerky upper extremity movements and snorts like a horse. Parkinsonism c. Vital signs are within normal limits and he is afebrile. Adolescent rebellion file:///C|/Documents%20and%20Settings/ASUS/M. He is upset about his behaviors and feels like a “freak. which include hallucinations and delusions. The most likely diagnosis is: a. he is not exhibiting any tremors or other movements of the extremities. In addition. Akathisia d. His parents believe he is punishing them for setting limits on television and social time with his friends.Ovid: Ovid: Blueprints Psychiatry moving to feel better. Neuroleptic malignant syndrome e. A 15-year-old boy is brought to his pediatrician's office because his parents are embarrassed by his behavior. Dystonia b. They report that he has been intermittently barking and yelping repetitively during conversations. Tardive dyskinesia View Answer 44.” The most likely reason for the young man's behavior is: a. his psychotic symptoms.htm (35 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Other than pacing.. A serum creatine phosphokinase is drawn and is normal. Although he appears agitated. The young man denies any retaliation against his parents.lueprints%20Psychiatry/Questions%20-%201.

olanzapine 7.5 mg each evening. Schizophrenia c. Lithium toxicity b. Serotonin syndrome View Answer file:///C|/Documents%20and%20Settings/ASUS/M.htm (36 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . his heart rate is 100 and regular. and lorazepam 1 mg per day. and temperature is 98. respiratory rate is 14 breaths per minute. coarse tremor of his upper extremities.7°F. Fluoxetine toxicity d. Oxcarbazepine toxicity e. He reports that he has been sweating a great deal because it is “so hot outside” and that he gets “no relief” at home because his halfway house is not air-conditioned. He denies having used any illicit drugs. The most likely diagnosis is: a. Lorazepam toxicity c. blood pressure is 98/60 mm Hg. lithium carbonate 300 mg each morning and 600 mg each evening.. confusion. and diarrhea. His medications are fluoxetine 40 mg per day. Substance abuse d.lueprints%20Psychiatry/Questions%20-%201. oxcarbazepine 300 mg each morning and 900 mg each evening. A 41-year-old man with a 21-year history of bipolar disorder comes to the emergency department with ataxia. Conduct disorder View Answer 45. On examination.. Tourette's disorder e.Ovid: Ovid: Blueprints Psychiatry b.

Schizophreniform disorder b. Substance abuse history is unknown. Obsessive-compulsive disorder View Answer 47. A 23-year-old man is psychiatrically evaluated in the surgical intensive care unit after sustaining a self-inflicted gunshot wound to the abdomen. the next step in properly evaluating this patient is: a..Ovid: Ovid: Blueprints Psychiatry P. Atypical depression e. At this point.lueprints%20Psychiatry/Questions%20-%201. incoherent speech.126 46. To accept the patient's assertion that the event was accidental file:///C|/Documents%20and%20Settings/ASUS/M. On examination. An 18-year-old college student is brought to the emergency room by the campus police because he has created a disturbance on campus. and rapid. agitation. the patient is vague and guarded. The most likely diagnosis is: a. The length of time that he has had the symptoms is unknown. The patient is conscious but sedated following surgical intervention. He admits to drinking a few beers before the incident. On examination.htm (37 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .. He provides a history that he was not suicidal and that he accidentally shot himself while cleaning the gun. Winter depression c. he has auditory hallucinations. Generalized anxiety disorder d.

htm (38 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . To refer the patient to Alcoholics Anonymous e. Additional history obtained from a close friend reveals that the patient in the previous question had been despondent over a romantic breakup and worsening performance in college.lueprints%20Psychiatry/Questions%20-%201. Keep your findings secret from the patient so as not to provoke anger at his friends and family e. or witnesses to the event View Answer 48. The patient did not ingest alcohol routinely. Accept the patient's assertions that the gunshot was accidental b. it seems reasonable to: a. Discuss the patient's alcohol abuse with the patient d.. To obtain additional history from the patient and family. The patient's family reported that he had been avoiding them over the past few days.. Initiate pharmacological treatment with an antidepressant medication View Answer file:///C|/Documents%20and%20Settings/ASUS/M. To obtain a head CT c. friends. but he had drunk to the point of intoxication at least twice in the past week.Ovid: Ovid: Blueprints Psychiatry b. Based on the additional history. To obtain a thyroid-stimulating hormone level d. Discuss your findings with the patient and explain that you are concerned about the possibility of a suicide attempt c.

but that she just can't sit still. 3 days ago. He states. Neuroleptic malignant syndrome b. Caffeine intoxication View Answer 50. “I think the doctors are trying to kill me.. The staff reports that he has been progressively sedated and confused for the past 24 hours. She notes that she doesn't know what is happening.lueprints%20Psychiatry/Questions%20-%201. you note that he was admitted 1 week prior and was restarted on his usual dose of carbamazepine because of a low level.htm (39 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Generalized anxiety disorder d. The most likely diagnosis is: a. On your examination. You prescribe a selective serotonin-reuptake inhibitor antidepressant for a patient suffering from major depression requiring an inpatient psychiatric admission. she appears markedly anxious. and 2 days later. feeling like she has to move her legs around. You conduct a thorough file:///C|/Documents%20and%20Settings/ASUS/M.. Then. The nursing staff is very concerned. the patient is agitated and pacing. A 53-year-old man admitted to the inpatient psychiatric unit for treatment of bipolar disorder is found lying in the hallway. and is unable to focus on the conversation. His last carbamazepine level was measured 3 days ago. he is conscious but is confused and dysarthric. he developed an upper respiratory infection and was treated with an antibiotic. bouncing her legs up and down during your interview.Ovid: Ovid: Blueprints Psychiatry 49. On examination. Medication-induced akathisia c. suggesting the patient may need additional sedation. Serotonin syndrome e.” Upon reviewing his chart.

The most likely subtype of schizophrenia in this patient is: a. Dementia c. Drug toxicity d.. Paranoid b. Other than these unusual beliefs. Catatonic c.htm (40 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Malingering b. A 22-year-old man who was recently fired from his job as an auto mechanic presents in the emergency room complaining of a conspiracy against him at his former workplace. You think about referring him to a lawyer when he informs you that his boss is an alien emperor from Jupiter and that his coworkers are the emperor's loyal subjects. Normal pressure hydrocephalus View Answer 51. it sounds like possible workplace harassment. Disorganized file:///C|/Documents%20and%20Settings/ASUS/M.. Progressive upper respiratory infection e. The most likely diagnosis is: a. When he first begins to explain the situation.lueprints%20Psychiatry/Questions%20-%201.Ovid: Ovid: Blueprints Psychiatry physical and review of systems to assure yourself that the patient did not suffer a syncopal episode and wasn't injured when he fell. he coherently elaborates a richly detailed story about the aliens at the garage and how they conspired to eliminate him. When you ask him to describe the situation more. he appears normal in terms of dress and body posture.

.127 reports to you that the patient has developed a hand tremor that looks like he is rolling a pill. The nurse P. Benztropine c. You are asked to see a 27-year-old man who was discharged 2 days ago from a psychiatric hospital. Residual View Answer 52. He reports a history of daily alcohol use since the age of 9 years except for rare periods of sobriety during brief stints in jail or in hospitals..lueprints%20Psychiatry/Questions%20-%201. Undifferentiated e. Clozapine e. Haloperidol View Answer 53.Ovid: Ovid: Blueprints Psychiatry d. Which of the following medications would be most likely to have caused this condition? a. Lorazepam b. Quetiapine d. He is currently taking opiate pain relievers for leg pain file:///C|/Documents%20and%20Settings/ASUS/M.htm (41 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . A 43-year-old male is admitted to the hospital for a leg fracture sustained after falling from a ladder while intoxicated with alcohol. He also tells you that the patient is walking very stiffly and appears to be having trouble initiating his movements.

Continue his current treatment regimen with downward adjustments in opiate and benzodiazepine dosing as pain and alcohol withdrawal symptoms subside b. Stop benzodiazepines because he may become addicted to them e.. Add an antidepressant medication to his current treatment regimen View Answer 54. Add naltrexone to his current treatment regimen to treat alcohol dependence c.htm (42 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .Ovid: Ovid: Blueprints Psychiatry and is receiving thiamine. The best treatment recommendation would include: a. Stop opiate pain relievers because he may become addicted to them d. Alcoholics Anonymous. cognitive-behavioral therapy. Oxazepam monotherapy file:///C|/Documents%20and%20Settings/ASUS/M. Appropriate management at this point would include: a.. The patient in the previous question recovers nicely from his fracture and has a successful detoxification from alcohol. Cognitive-behavioral therapy d. Naltrexone monotherapy c. folate. Alcoholics Anonymous e. The patient expresses an interest in future treatment options for alcohol dependence.lueprints%20Psychiatry/Questions%20-%201. and benzodiazepines for alcohol withdrawal. Duloxetine monotherapy f. He has not required opiate pain relievers or benzodiazepines for the past week. and naltrexone b.

She states that her mood improved shortly after beginning fluoxetine.Ovid: Ovid: Blueprints Psychiatry g.lueprints%20Psychiatry/Questions%20-%201. Providing an appropriate level of information for a patient with mental file:///C|/Documents%20and%20Settings/ASUS/M. She is speaking quickly and appears distractible. Begin cognitive-behavioral therapy View Answer 56. the patient is hypoxic. Begin a mood stabilizer and stop fluoxetine d. Schedule electroconvulsive therapy c. Acamprosate monotherapy View Answer 55.htm (43 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .. Emergency personnel ascertain that the patient has an upper airway obstruction and will require an emergency tracheotomy. Increase her fluoxetine b. A 50-year-old mentally retarded patient with schizophrenia presents to the emergency room with airway obstruction. A 20-year-old woman who presented to your office 1 month ago with postpartum depression returns for follow-up. Her energy is greatly improved. She states she has cleaned her house several times and is only sleeping 2 to 3 hours each night.. On presentation. What would be the critical issues regarding informed consent with this patient? a. The most appropriate treatment would be: a. Begin dialectical behavioral therapy e.

Selective serotonin-reuptake inhibitor View Answer file:///C|/Documents%20and%20Settings/ASUS/M. Monoamine oxidase inhibitor e.htm (44 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Lithium d. He also has difficulty falling asleep at night. The symptoms are threatening his job and his relationship with his wife. The patient should be committed e. Electroconvulsive therapy b. Ensuring that the consent is voluntary d.. He has lost 20 pounds during this time.lueprints%20Psychiatry/Questions%20-%201. The most appropriate agent for initial treatment of this condition would be: a. He complains of decreased interest and pleasure in his work and hobbies. For the past month. A 45-year-old man presents 3 months after a myocardial infarction he sustained at his place of employment where he works as the head chef. Establishing competence in a hypoxic mentally retarded patient with schizophrenia c. he has been having trouble concentrating and remembering his recipes. He has had very little energy despite successful cardiac rehabilitation. Informed consent is not necessary View Answer 57.Ovid: Ovid: Blueprints Psychiatry retardation and schizophrenia b. Tricyclic antidepressant c..

Electroconvulsive therapy c. and often speaks out in class without having been called on. The most appropriate treatment for this patient is: a. Inpatient psychiatric admission to a dual-diagnosis unit e.lueprints%20Psychiatry/Questions%20-%201. He has had file:///C|/Documents%20and%20Settings/ASUS/M. During the interview... but she subsequently realized they were total fakes. Begin long-term psychodynamic psychotherapy View Answer 59. She has a history of a polysubstance abuse but denies any recent substance P. She has been married and divorced three times. She reports persistent financial concerns. His mother states that he is very difficult to manage at home. A 30-year-old woman presents with the chief complaint that everyone always leaves her. She reports that her parents divorced when she was 4 and that she was raped by her stepfather numerous times from the ages of 6 to 10. At school. She states that each husband initially seemed perfect. She has had more than 60 sexual partners. Begin antipsychotic medication b.128 abuse history. frequently forgets his homework. the patient is alternately seductive and irritable. An 8-year-old boy is brought to your office for evaluation of difficulties in the home and at school. She expresses chronic feelings of emptiness. he seems to have difficulties following instructions. Dialectical behavioral therapy d.Ovid: Ovid: Blueprints Psychiatry 58.htm (45 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .

htm (46 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Atomoxetine and behavioral therapy d. A 4-year-old boy watches his father use a fork.lueprints%20Psychiatry/Questions%20-%201. Psychodynamic psychotherapy c. Modeling d. Venlafaxine b. You have been called to evaluate a patient in the emergency department. Regression c. Supportive psychotherapy f. Haloperidol View Answer 60. Operant conditioning View Answer 61. Classical conditioning e.Ovid: Ovid: Blueprints Psychiatry psychological testing that demonstrates an above-average IQ and no evidence of learning disability.. Which of the following will be the most appropriate means to manage this boy? a. This is an example of: a.. The child then raises a fork and uses it in a similar fashion to feed himself. Projection b. Citalopram and cognitive therapy e. The file:///C|/Documents%20and%20Settings/ASUS/M.

Akathisia e. Venlafaxine file:///C|/Documents%20and%20Settings/ASUS/M. He appeared to respond but then began to demonstrate agitation that was then treated with oral olanzapine. He has a long history of schizoaffective disorder. She reports that she was uncharacteristically promiscuous and states that this behavior was followed by a period of irritability. These issues were followed by the current depressive episode. He became delirious with unstable blood pressure and diaphoresis.htm (47 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .lueprints%20Psychiatry/Questions%20-%201. and then seizures. Initially. Serotonin syndrome b. he was managed with several doses of intramuscular haloperidol.. Disulfiram-related toxicity View Answer 62. and she was unbelievably productive in her work. rigidity. she states that she had not needed any sleep. Which of the following agents would be most appropriate for her maintenance therapy? a. fever. Neuroleptic malignant syndrome c. Dystonia d.. difficulty concentrating. What is his likely diagnosis at this time? a. and a persistent inability to sleep. She states that she was doing very well up until 1 week previously. In fact. A college student presents with symptoms of depression. her creativity was at an all-time high. The patient has been present for three emergency ward shifts. The patient then became increasingly agitated and received high-dose intramuscular ziprasidone.Ovid: Ovid: Blueprints Psychiatry patient had been highly combative.

ECT is indicated only for refractory depression d. Electroconvulsive therapy e.. A patient with treatment-refractory depression has received electroconvulsive therapy (ECT). she has been awake for 2 or 3 days with constant talking and activity. Bilateral ECT is more effective than unilateral c. the patient is agitated. and appears a bit paranoid.htm (48 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . The most appropriate action is: a.lueprints%20Psychiatry/Questions%20-%201. An 85-year-old woman with no prior psychiatric history is evaluated in the emergency department for odd behavior.Ovid: Ovid: Blueprints Psychiatry b. Lithium d. On examination. According to the patient's family. Bilateral ECT has fewer side effects than unilateral b. To treat the patient with a mood stabilizer for bipolar disorder file:///C|/Documents%20and%20Settings/ASUS/M. ECT is contraindicated in psychosis View Answer 64. pacing the room. Mirtazapine c. Which of the following is true of this treatment? a.. talking nonstop and not allowing you to interrupt her. The most common side effect is seizures e. Valium (diazepam) View Answer 63.

A nutritional consult b. The most important initial management for this patient would include: a.htm (49 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . He has lost a great deal of weight and has not been sleeping or grooming himself well. The patient denies depression or suicidal thinking and states that he was planning to clean the gun and that he keeps the gun for prowlers. To order a thorough medical and neurological workup e.lueprints%20Psychiatry/Questions%20-%201. Psychiatric hospitalization c. Neurological consultation View Answer 66.. A 72-year-old white man presents to the emergency ward after his daughter found him sitting on his bed with a loaded pistol in his hand.129 d. Outpatient psychopharmacology referral e. The patient's daughter reports that he has seemed despondent since his wife died a few months ago.Ovid: Ovid: Blueprints Psychiatry b. To treat the patient with an antipsychotic medication for schizophrenia View Answer 65.. To treat the patient with an antidepressant medication d. Two elements of the previous patient's history indicate that he is at increased file:///C|/Documents%20and%20Settings/ASUS/M. To treat the patient with synthetic thyroid hormone replacement c. Outpatient psychotherapy referral P.

Hopelessness d. race. he continues to worsen and is unable to eat or drink.. appropriate treatment for this patient includes: a. Dialectical behavioral psychotherapy c. The patient in Question 67 is admitted to the hospital. Propanolol d. Lack of sleep c. Once hospitalized in a secure setting. and gender e. He has severe psychomotor retardation and has little spontaneous speech. Poor grooming View Answer 67. Mirtazapine e. The first is major depression.Ovid: Ovid: Blueprints Psychiatry risk for suicide. Valproate View Answer 68. however. Age. He continually ruminates about his hopelessness and desire to die. The second is: a.lueprints%20Psychiatry/Questions%20-%201. Buspirone b. Weight loss b.htm (50 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . and treatment is initiated with mirtazapine.. A reasonable next step in treating this patient is: file:///C|/Documents%20and%20Settings/ASUS/M.

htm (51 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .” Upon examination. Add gabapentin View Answer 69. disheveled.” The most likely diagnosis at this point is: a.Ovid: Ovid: Blueprints Psychiatry a. the young man appears agitated. He has been handcuffed to the bed by hospital security and is straining at his restraints. but the police indicate that the man was repeatedly accusing them of working for the National Security Agency and having a plan to “put me away. The nature of the disturbance is unclear. Decrease the mirtazapine b. Attention-deficit/hyperactivity disorder d. and he is very upset that you wish to measure his vital signs with the equipment in the room... He states. “You are going to give me away. Hypothyroidism file:///C|/Documents%20and%20Settings/ASUS/M. Heroin intoxication c. Cognitive-behavioral therapy d. His speech is quite pressured. Panic disorder b. A 22-year-old man is brought to the local emergency ward by the police after being arrested in a grocery store for causing a disturbance. Multivitamins e. Evaluate the patient for electroconvulsive therapy c. Schizophrenia. paranoid subtype e. and frightened.lueprints%20Psychiatry/Questions%20-%201.

Modafinil to improve daytime alertness e. He remains alert during the drop attacks but does fall to the floor. The available history indicates that the patient was involved in a motor vehicle accident 72 hours ago in which he sustained a tibial fracture requiring surgical procedures for repair.htm (52 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . The patient suffered no head injury or loss of consciousness during the accident.lueprints%20Psychiatry/Questions%20-%201. Valproic acid to treat seizure activity d. He feels refreshed after a daytime nap. He notes that he sometimes has an irresistible urge to sleep and has fallen asleep on multiple occasions even while driving. Administration of zolpidem (Ambien) at bedtime to improve nighttime sleep c. A 27-year-old man complains of excess sleepiness during the day and having intense dreams at times when he thinks he is still awake. Continuous positive airway pressure at night to improve abnormal breathing during sleep b. A 57-year-old man with a past medical history of “liver problems” is seen in psychiatric consultation in the hospital intensive care unit because of agitation and confusion.Ovid: Ovid: Blueprints Psychiatry View Answer 70. An appropriate treatment intervention is: a.. Upon questioning. His medications since arriving in the hospital file:///C|/Documents%20and%20Settings/ASUS/M.. he reports that he sometimes has “drop” attacks characterized by sudden weakness in his whole body. Olanzapine to improve daytime alertness View Answer 71.

and thrombocytopenia. Transfusion of packed red blood cells b. His minimum daily consumption of alcohol consists of file:///C|/Documents%20and%20Settings/ASUS/M. Dementia b.Ovid: Ovid: Blueprints Psychiatry have included only antibiotics and opiate pain relievers. Administration of intravenous thiamine e. Increase in the dosage of opiate pain reliever View Answer 73. The diagnosis most consistent with agitation and confusion in this patient is: a.. Akathisia View Answer 72. A potentially critical treatment or diagnostic intervention at this point would include: a. leukopenia. Additional history obtained from the above patient's family indicates that he drinks alcohol on a daily basis. Antisocial personality disorder e.lueprints%20Psychiatry/Questions%20-%201. Psychotic disorder c. Delirium d..htm (53 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . The laboratory results for the patient in Question 71 include elevations in multiple liver enzymes with moderate anemia. Evaluation for pulmonary embolism c. Administration of an antidepressant medication d.

Intravenous hydration to treat tachycardia d. An appropriate pharmacological intervention might include: a. A benzodiazepine medication c.130 c. An opiate analgesic medication file:///C|/Documents%20and%20Settings/ASUS/M. An antidepressant medication of the selective serotonin-reuptake inhibitor class b.htm (54 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . He expresses a desire to stop drinking alcohol and requests treatment for alcohol dependence. A benzodiazepine to treat withdrawal symptoms e. The patient's vital signs reveal a heart rate of 130 beats per minute and a blood pressure of 180/110 mm Hg. The patient in Question 73 responds to treatment. Buspirone to treat withdrawal symptoms b. An additional critical treatment at this point would include: a..lueprints%20Psychiatry/Questions%20-%201. He is successfully tapered from benzodiazepines and has not required opiate pain relievers for the past 7 days. An antihypertensive medication d. Propanolol to treat hypertension and tachycardia P..Ovid: Ovid: Blueprints Psychiatry a 12-pack of regular beer. but he often consumes more than twice that amount. and his confusion and autonomic instability resolve. Clonidine to treat hypertension View Answer 74.

Asperger's syndrome b. She states that file:///C|/Documents%20and%20Settings/ASUS/M. Anxiety disorder not otherwise specified e. She is awkward in her interactions. Naltrexone View Answer 75. Autism c. Posttraumatic stress disorder View Answer 76.lueprints%20Psychiatry/Questions%20-%201.Ovid: Ovid: Blueprints Psychiatry e. Her foster mother says that she can be quite verbally articulate and writes extremely well. She has trouble seeing the “big picture” of problems that face her. A 12-year-old girl presents with her foster mother for a routine pediatric visit. The most likely diagnosis is: a. Once you ask her about one of her projects. She denies any significant anxiety.. You query her for depressive or psychotic symptoms and she denies either. The girl seems quiet. Avoidant personality disorder d. Her foster mother says that the girl has been having difficulties socially in school.htm (55 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . A 40-year-old woman presents to your office for the first time. She has trouble making friends and often has conflicts with classmates. She engages with you briefly but still appears uncomfortable. and she does not make eye contact with you as you enter the room.. she tells you about the intricacies of building a radio from scratch. and she often gets lost in the details of projects that she is assigned.

She blames herself for the failure of her marriage and feels horribly guilty about how the failure of her marriage is affecting her children. Decreased stage 2 sleep d. you see that you hospitalized her for a major depressive episode 1 year ago in August.Ovid: Ovid: Blueprints Psychiatry she has never seen a psychiatrist before. Her friends are concerned because she has not been joining them for their weekly “girls' night out. Sleep studies have revealed that which of the following sleep disturbances occur in depression: a. She also complains of difficulty falling asleep and says that she hasn't felt rested in months. You have been treating a 56-year-old woman for bipolar disorder for the last 15 years. she does not even get out of her pajamas. but her friends encouraged her to make the appointment because they are worried about her. Increased latency to REM b. She says she has felt so down that she has rarely left her house and on some days.htm (56 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . She tells you that since her divorce 4 months ago. She reports she has lost about 15 pounds because she has no appetite. In reviewing your notes regarding her clinical course over the last year. she has been crying all the time... You diagnose the patient as being in the midst of a major depressive episode. In file:///C|/Documents%20and%20Settings/ASUS/M. Decreased stage 4 sleep e. Increased delta sleep c. Decreased time spent in REM View Answer 77.lueprints%20Psychiatry/Questions%20-%201.” She says she just has no desire to do anything that she used to enjoy.

She was doing well in January but then slid into another major depressive episode in February that you were able to treat with medication as an outpatient. With atypical features c. You realize that this woman has had four episodes in the last 12 months that met the criteria for either a major depressive episode or a manic episode.. Also. The medication is most likely to be: a. her husband called your office because she was demonstrating symptoms of mania again. You explain to the patient that you will monitor levels of this medication regularly. she had an acute manic episode requiring another hospitalization. With rapid cycling View Answer 78. you recommend changing the patient's treatment.Ovid: Ovid: Blueprints Psychiatry November. With catatonic features b. With postpartum onset d. After refining your diagnosis to bipolar I disorder with rapid cycling in the patient in Question 77.lueprints%20Psychiatry/Questions%20-%201.htm (57 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . With seasonal pattern e. Just last month in April. Lithium file:///C|/Documents%20and%20Settings/ASUS/M.. You recommend a mood stabilizer that is more effective for the rapid-cycling variant of bipolar disorder. What would be the correct specifier to apply to her diagnosis of bipolar I disorder? a. you explain that you need to check her liver function prior to starting the medication and frequently during the first 6 months.

Glutamate file:///C|/Documents%20and%20Settings/ASUS/M. A 51-year-old woman with a long-standing diagnosis of obsessive-compulsive disorder describes her symptoms to you..Ovid: Ovid: Blueprints Psychiatry b.htm (58 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . She also checked under both the bathroom and kitchen sinks to make sure that there was no water leak. Dopamine b. she now spends less than 2 hours per day engaged in these repetitive checking behaviors. Gabapentin View Answer 79. As a result of these thoughts.131 stove. Carbamazepine e. She reports that since beginning treatment with fluvoxamine approximately 5 years ago. Lamotrigine d. iron.lueprints%20Psychiatry/Questions%20-%201. She reports recurrent intrusive thoughts that her apartment is going to be destroyed by fire or water damage. and bathroom fan are turned off. Which of the following neurotransmitters has been implicated as a mediator of obsessive thinking and compulsive behaviors? a. Norepinephrine c. she used to spend approximately 6 hours a day checking to make sure the P. Valproate c..

The mother nods her head and concurs saying. She would also repeatedly and excessively clean the family home so that “one could eat off the floor. her mother was very angry because a teenager from the neighborhood kept cutting through her daughter's backyard rather than using the sidewalk. Her daughter says. The daughter reports that her mother has always paid painstaking attention to rules. “I have been a perfectionist all my life.. “She just can't let it go. Her daughter states that if her mother misplaced the list.. and schedules. there is one and only one way to load the dishwasher. Narcissistic personality disorder file:///C|/Documents%20and%20Settings/ASUS/M.lueprints%20Psychiatry/Questions%20-%201.Ovid: Ovid: Blueprints Psychiatry d.” Based on the information provided.” The daughter states that her mother becomes very frustrated when others do not meet her moral and ethical standards. this patient's most likely diagnosis is: a. GABA View Answer 80. Serotonin e. This is your first meeting and you ask the daughter to describe her mother's personality. Antisocial personality disorder b.htm (59 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Recently. She would spend weeks packing in preparation for family vacations. The daughter says her mother always needed every detail of a project to be perfect. she would spend an inordinate amount of time looking for the list rather than just rewriting it.” She says that her mother is “extremely stubborn” and always insists that things be done “her way. A 71-year-old woman comes to your office accompanied by her adult daughter. lists. For example.” For example. she would always make detailed “to do” lists.

date. Capacity View Answer 82. and time.lueprints%20Psychiatry/Questions%20-%201.. Consent b. Concrete logic d. The consultant explains in detail the reason the catheter is indicated and the medical consequences of failing to receive appropriate treatment.” Which element of informed consent has this patient partially satisfied? a. Obsessive compulsive disorder d. On examination.. the patient is alert and oriented to person. place. The medical team requests that the psychiatric consultant assess the patient's ability to consent to medical procedures. An 87-year-old woman with a history of mild mixed dementia is admitted for confusion and a urinary tract infection.htm (60 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .Ovid: Ovid: Blueprints Psychiatry c. You are working in an outpatient psychotherapy clinic when your patient tells file:///C|/Documents%20and%20Settings/ASUS/M. the patient becomes agitated and refuses the catheter. Schizoid personality disorder e. Duty e. “I don't want a catheter. Information c. When the nurse attempts to place a Foley catheter to improve urine drainage. The patient states. Obsessive compulsive personality disorder View Answer 81.

hypercholesterolemia. Swedish Common Law e. You realize that you must attempt to warn the patient's landlord about the patient's statements. the patient bolts from the office and escapes. The patient complains of chest pain. On examination. The M'Naghten rule c.5 packs of cigarettes per day.. Negligence View Answer 83. He does not recall a prior diagnosis of hypertension. Before you can react. Connecticut d. You tell the patient that you are quite concerned about these homicidal feelings and recommend inpatient psychiatric admission.htm (61 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .. The patient calls the landlord by name and mentions that he lives just down the street from her. diaphoretic. A critical diagnostic test at this point is: file:///C|/Documents%20and%20Settings/ASUS/M. he is nervous. He has no known prior history of “heart trouble” and denies alcohol or drug use. An electrocardiogram reveals sinus tachycardia with ST-segment depressions in the anterior leads. and pacing. The patient smokes 1. His vital signs indicate a heart rate of 132 beats per minute with a blood pressure of 175/100 mm Hg.Ovid: Ovid: Blueprints Psychiatry you that she plans to kill her landlord. Your actions are grounded in which of the following legal precedents? a. A 29-year-old man is dropped off by friends at the emergency department. The patient is afebrile. Griswold v.lueprints%20Psychiatry/Questions%20-%201. The Tarasoff decision b. or diabetes.

Polydrug abuse b. Urine drug screen d.132 pain with cocaine-positive urine tests over the last year. he states that he rarely uses cocaine. Liver function tests View Answer 84. Electroencephalogram c.lueprints%20Psychiatry/Questions%20-%201. Antisocial personality disorder c. however. Upon checking the patient's chart from prior visits.Ovid: Ovid: Blueprints Psychiatry a. Hematocrit e. it is clear that the patient has had several emergency ward visits for chest P. Malingering file:///C|/Documents%20and%20Settings/ASUS/M. At this point. you can make the following diagnosis with confidence: a. A urine test obtained on the patient in Question 83 reveals cocaine and cocaine metabolites in the urine specimen.. and this was the first time in many months. Cocaine dependence d. Upon confrontation. The patient has a mild myocardial infarction without significant arrhythmia or other complications.htm (62 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Abdominal ultrasound b. Myocardial infarction e..

The brain stem and frontal lobes b..lueprints%20Psychiatry/Questions%20-%201. and a fear of losing control. A 25-year-old female has episodes of recurrent. The thalamus and cingulate gyrus d. and mammillary bodies c. fornix. The caudate and putamen e. The hippocampus. Glycine b.Ovid: Ovid: Blueprints Psychiatry View Answer 85. chest pain. diaphoresis. GABA View Answer file:///C|/Documents%20and%20Settings/ASUS/M. A 57-year-old man with a history of chronic alcoholism is placed in a nursing home for alcohol-related amnestic disorder. She avoids socializing and shopping because she fears the episodes will recur.htm (63 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Enkephalin e. Melatonin c.. Substance P d. unexpected anxiety. The cerebellum View Answer 86. with palpitations. Alterations in the following neurotransmitter system are strongly linked to this disorder: a. This condition is associated with damage to the following brain regions: a.

She feels that everyone notices it and has gone to a number of plastic surgeons to try to get it corrected.” and other times he is pleased with the scores that he achieves. He sometimes thinks he is “useless” if he doesn't score at a game. Industry versus inferiority e. The father says the child is developing well. Intimacy versus isolation b. He began playing soccer 2 years ago. The son tells you that he feels like he is a good player and only sometimes thinks that he is the worst player on the team. the boy is dealing with what developmental conflict? a. According to Erikson's life cycle stages. An 11-year-old boy presents in your outpatient clinic with his father for a routine visit. Identity versus role confusion c. Ego integrity versus despair View Answer 88.Ovid: Ovid: Blueprints Psychiatry 87. The father said that the boy is sometimes a “sore loser. A 24-year-old woman presents in the emergency department complaining that her nose is crooked.” she says pointing to her nose. Initiative versus guilt d.htm (64 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . “See. She pulls out a mirror and looks at herself.lueprints%20Psychiatry/Questions%20-%201. “don't you see how ugly it is?” She tells you that she cannot continue walking around in public with this nose.. The father said that he praises the boy whether he scores or not and tries to teach him new techniques for improving his game when they play together on the weekends.. You examine her and find no evidence that it is abnormal. None has been willing to operate on her file:///C|/Documents%20and%20Settings/ASUS/M.

htm (65 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Pick's disease c. Alzheimer's disease b. states that the patient has become apathetic.lueprints%20Psychiatry/Questions%20-%201. Huntington's chorea d. He has documented mild memory difficulty. What is your diagnosis? a. A 50-year-old man is brought to your office by his family. A workup to date has included thiamine. The family. Vascular dementia e.. Body dysmorphic disorder b. inconsiderate. He has no history of coronary artery disease or hypertension. An HIV test was negative. Borderline personality disorder d. Social phobia e. all of which were normal. A head CT scan with and without contrast demonstrated frontal and temporal atrophy. The patient has: a. Posttraumatic stress disorder View Answer 89. vitamin B12. Exhibitionism c. and neglects his personal care. Creutzfeldt-Jakob disease file:///C|/Documents%20and%20Settings/ASUS/M. and she draws the same conclusion as you.Ovid: Ovid: Blueprints Psychiatry nose to fix it. however.. folate. You ask a colleague to examine the patient. He states that he is doing fine and that he has no memory trouble. niacin levels.

Ovid: Ovid: Blueprints Psychiatry View Answer 90. A 57-year-old man from out of town sees you in the walk-in clinic to obtain replacement prescriptions because his original prescriptions have been lost. but her mood has remained a problem. Dialectical behavioral therapy View Answer 91. Cognitive-behavioral therapy b. Psychoanalytic psychotherapy c. She has had long-standing problems with mood and significant difficulties with interpersonal relationships. he is prescribed a medication that his P. In the end. Behavior therapy e. she felt that she understood herself a lot better and could have better relationships.lueprints%20Psychiatry/Questions%20-%201.133 file:///C|/Documents%20and%20Settings/ASUS/M. The patient was likely undergoing what kind of treatment? a. She tells you that she was in psychotherapy for 5 years with a doctor from another city. Interpersonal therapy d. her relationships with her parents.. A 46-year-old woman presents to you for an initial psychiatric evaluation. She met with him several times a week and describes talking with him about her early childhood.. He explains to you that he is a recovering alcoholic with depression and anxiety. In addition to paroxetine. and subsequent relationships with important people in her life.htm (66 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ .

Naltrexone e. Zolpidem c. Disulfiram b... A 45-year-old alcoholic man with hepatic cirrhosis is admitted for alcohol detoxification.lueprints%20Psychiatry/Questions%20-%201. Chlordiazepoxide d. Buspirone file:///C|/Documents%20and%20Settings/ASUS/M. Diazepam c. Metoclopramide View Answer 92. She tells you that. The attending physician on call instructs you to treat the patient with routine treatment including thiamine. Oxazepam b. you should choose a benzodiazepine that is metabolized by conjugation and that doesn't have long-acting metabolites. He thinks the medicine may have worked because he lost interest in continuing drinking the next day and has not relapsed since. because the patient likely has impaired hepatic metabolism. A reasonable choice is: a. He can't recall the name of the medication. The medication is most likely to be: a. but he did drink a large amount of alcohol one time since he has been on it and did not feel ill. folate.htm (67 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . and benzodiazepines. Buspirone d.Ovid: Ovid: Blueprints Psychiatry doctor at home said would decrease his cravings for alcohol.

” After learning a bit about the patient.lueprints%20Psychiatry/Questions%20-%201. hypercholesterolemia. HIV-related dementia View Answer 94. In thinking about delirium. hypertension. He reports that he rarely has a sexual fantasy and almost never has an interest in sex. In reviewing this patient's history. This patient has a disturbance in what phase of the sexual response cycle? file:///C|/Documents%20and%20Settings/ASUS/M. you learn that he has a 40-pack-year history of cigarette smoking. A 23-year-old man seeks psychological counseling because he is worried that he isn't “normal. This patient has known risk factors primarily for what type of dementia? a. A 73-year-old man is admitted to the hospital for lobar pneumonia and develops delirium. and coronary artery disease.. you remember that dementia is a risk factor for the future development of delirium.Ovid: Ovid: Blueprints Psychiatry e. Creutzfeldt-Jacob-related dementia d. type 2 diabetes mellitus. you ask him to tell you what he needs help with. Clonazepam View Answer 93. The patient states that he thinks his sex drive is much lower than that of his peers. Parkinson's-related dementia e.htm (68 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Huntington's-related dementia b. Vascular-related dementia c..

He states that he sleeps alone after his last bed partner complained that he snored very loudly and sounded like he was choking all night. Desire c. He has been increasing his caffeine intake to the point that he feels jittery and nervous. you make the following provisional diagnosis for the patient's complaints: a. A 56-year-old man with a history of mild hypertension and obesity presents to his primary care physician for treatment of daytime sleepiness and fatigue. Major depression file:///C|/Documents%20and%20Settings/ASUS/M. you ask the patient about his time in bed at night. dozes off quite frequently during the day.Ovid: Ovid: Blueprints Psychiatry a. Hypochondriasis d. Plateau View Answer 95. Orgasm e. and has fairly frequent headaches. Resolution d. Hypothyroidism b. Hyperthyroidism c. After completing the interview.lueprints%20Psychiatry/Questions%20-%201.htm (69 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . After obtaining a detailed medical and psychiatric history. Excitement b. The patient reports that he has been becoming progressively more fatigued over the past 2 to 3 years and has gained around 25 pounds because he has no energy to move around.. but he is still tired..

the following drug is commonly used as a maintenance medication for individuals with opioid dependence. Narcolepsy View Answer 96. The goal is to alleviate drug hunger and minimize drug-seeking behavior.. As an emergency department triage officer.Ovid: Ovid: Blueprints Psychiatry e.licensed clinics. The drug is administered in government. Crack cocaine b. It is a weak agonist at the µ-opiate receptor and has a half-life of 15 hours. Barbiturates e. A patient in withdrawal from which of the following medications would most likely necessitate admission? a. Whereas it is understood that any patient might necessitate admission. you have been asked to develop a protocol for admissions. Nicotine View Answer 97. Heroin b. Morphine file:///C|/Documents%20and%20Settings/ASUS/M. Marijuana d.htm (70 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Sleep-related breathing disorder f. The drug described is: a. Crystal methamphetamine c.lueprints%20Psychiatry/Questions%20-%201.. some conditions are generally self-limited. Because of its long half-life.

. The patient reports that he's been injecting himself with P. A 35-year-old anesthesiologist is referred to you. You tell him that one option is Suboxone. he would find himself in significant opioid withdrawal. Hydromorphone View Answer 98.. He is interested in learning about his treatment options. What medication is found in Suboxone that would account for this phenomenon? a.lueprints%20Psychiatry/Questions%20-%201. for treatment of opioid dependence. They staged an intervention that led to his referral here. You caution the patient that if he were to crush the Suboxone and inject it intravenously. Hydrocodone e. Buprenorphine b. Methadone c. an FDA-approved outpatient treatment for opioid dependence. He has tried to quit on his own several times but finds the withdrawal symptoms to be unbearable. You explain that Suboxone is a pill that dissolves sublingually.Ovid: Ovid: Blueprints Psychiatry c. Colleagues at the hospital where he works began to notice changes in his behavior and occupational performance. Naloxone file:///C|/Documents%20and%20Settings/ASUS/M.134 gradually increasing doses of fentanyl for the past year. an addiction psychiatrist.htm (71 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Methadone d.

. Exhibitionism b.Ovid: Ovid: Blueprints Psychiatry d. Flumazenil e. Acamprosate View Answer 99. At first. she appears embarrassed. A few seconds before the doors opened. and you ask her if everything is all right.” You file:///C|/Documents%20and%20Settings/ASUS/M.. Before she could say anything. An elderly man is referred to you by his internist because of symptoms of depression. you ask the patient if he has ever seen a psychiatrist before. the doors opened. She reports that since the subway car was crowded. Fetishism c.lueprints%20Psychiatry/Questions%20-%201. A 28-year-old female arrives at your office on time for her weekly psychotherapy session. She appears more distressed than usual. but then she confides in you that a disturbing incident occurred on the subway on the way to your office. She wasn't able to get a look at him. The patient reports that he indeed had seen a psychiatrist for several sessions about 30 years ago for a “swallowing problem. As you are taking a thorough history. This man likely suffered from a paraphilia called: a. she had to stand. Voyeurism View Answer 100. Pedophilia e. she suddenly felt a man rubbing his genitals against her back.htm (72 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . Frotteurism d. and the man was gone.

htm (73 of 73) [30/01/2009 06:23:11 ‫]ﻡ‬ . His primary care physician could not find a medical reason for his difficulty swallowing and referred the patient to a psychiatrist for this problem. The surgeon told the patient that he might need a radical surgery. The most likely diagnosis was: a.lueprints%20Psychiatry/Questions%20-%201. Hypochondriasis d. the patient reports he began having difficulty swallowing. nose. Body dysmorphic disorder e. Conversion disorder c. Fortunately. and it was so bad that he couldn't swallow solid food. all the tests came back negative.. Factitious disorder View Answer file:///C|/Documents%20and%20Settings/ASUS/M.. however. and the surgery was not recommended. After that. and throat surgeon.Ovid: Ovid: Blueprints Psychiatry ask for more details. and the patient explains that he had felt a knot near his throat and had gone to see an ear. Somatization disorder b.

. An 18-year-old male has been newly diagnosed with schizophrenia. Diabetes mellitus d. and HDL cholesterol is low at 20. you see him in your outpatient psychiatry clinic for routine follow-up.. LDL cholesterol is elevated at 180.htm (1 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Ronald L. Prior to the patient's psychiatric hospitalization. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Back of Book > Questions Questions 1.Ovid: Blueprints Psychiatry Authors: Murphy. You weigh the patient and request laboratory tests. Cataracts c. He reports that his psychiatric symptoms are under good management but complains that he has gained 10 pounds in weight since discharge from the hospital. Cowan. Michael J. You find that total cholesterol is elevated at 262.20Folder/Blueprints%20Psychiatry/Questions. One month later. you note that his lipid profile was within normal limits. Leukopenia View Answer file:///C|/Documents%20and%20Settings/ASUS/My%.. Which other medical condition is the patient at risk of developing? a. Diabetes insipidus b. He was admitted to the inpatient psychiatry ward and started on the atypical antipsychotic olanzapine. triglycerides are elevated at 250. Hypothyroidism e. Title: Blueprints Psychiatry.

20Folder/Blueprints%20Psychiatry/Questions.. he called the police. She had never spoken to the man. Her belief that this man was in love with her would be categorized as what type of delusion? file:///C|/Documents%20and%20Settings/ASUS/My%. heart problems. Nonketotic hyperglycemia c. sweating. The patient gives you permission to speak with his adult daughter who can provide information about the events leading up to the hospitalization. but she began to follow him around and spy on him.” She reports he takes a lot of medications but had to stop his “nerve medication” about a week ago because his insurance would no longer pay for it. and feeling weak. but she has never sought treatment. A 58-year-old man is transferred to your psychiatric facility after medical stabilization at an outside hospital. Yesterday. she found him in his room unresponsive with jerking movements of his arms and legs. She cannot recall the name of the medication.htm (2 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . and “bad nerves. A 39-year-old patient tells you that he believes his mother has been mentally ill for many years.. and she was found guilty of stalking in a court of law.Ovid: Blueprints Psychiatry 2. She reports that 3 to 4 days ago. The laboratory studies sent from the outside hospital do not indicate any gross abnormalities. Alcohol withdrawal View Answer 3. vomiting. he began complaining of nausea. Hyponatremia e. He tells you about an incident when his mother became convinced that the new neighbor who moved in across the street was in love with her. Acute stroke b. What was the most likely cause of this man's generalized seizure? a. Sedative-hypnotic withdrawal d. After a couple months. The daughter reports that her father has diabetes.

His mother reports that she has been trying to home school him. Major depressive disorder b. His mother decided to bring him to see a psychiatrist because for the last 2 months.20Folder/Blueprints%20Psychiatry/Questions. you discover that he had always been a good student until age 15 when his grades began dropping. Substance abuse disorder c. He began doing so poorly at school that he dropped out earlier this year. Somatic d. but he does not seem interested in learning.118 d. Erotomanic e.htm (3 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . In taking his history. Grandiose b. A 17-year-old male is brought to your office by his mother for an evaluation. she has overheard him having what sounds like conversations with someone in his room despite being alone. He does not seem to care about his appearance. Persecutory View Answer 4. His mother reports that she also noticed he stopped socializing with friends and began spending more time alone in his room. Jealous c. Schizophrenia P.Ovid: Blueprints Psychiatry a.. She says he seems preoccupied and has started to go days without bathing. Brief psychotic disorder file:///C|/Documents%20and%20Settings/ASUS/My%. What is his most likely diagnosis? a..

Direct causation c. You are asked to review the case. Duty b. Schizophreniform View Answer 5. and the diagnosis has only been well established for the past 5 years. Methylphenidate b..htm (4 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . One of his patients sustains a permanent injury that would not have occurred if the physician had made the correct diagnosis. His delusions and hallucinations are now well controlled. Which of the following elements is evidenced by this physician's unfamiliarity with the diagnosis? a. A 20-year-old man with schizophrenia has recently had a change in his antipsychotic medication. but he is complaining of some muscular rigidity. The physician finished his residency more than 20 years ago. Atenolol file:///C|/Documents%20and%20Settings/ASUS/My%.Ovid: Blueprints Psychiatry e.20Folder/Blueprints%20Psychiatry/Questions. Poor risk management View Answer 6. A physician is very attentive and compassionate with his patients. On questioning.. Damages d. Failure to meet standard of care e. Benztropine c. Which of the following agents would be an appropriate choice to address this new problem? a. Pemoline d. the physician is unaware of the diagnosis.

htm (5 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . you note that the patient has been diagnosed with psychotic disorder not otherwise specified. She has recently completed a workup for a seizure disorder. and has recently been started on scheduled haloperidol 5 mg by mouth twice per day. Briefly reviewing his chart. the patient has received up to three 5-mg doses of haloperidol per day for acute agitation since admission. Clonidine View Answer 7. he is looking upward. α-2 adrenergic antagonist b.. you are asked to urgently assess a 32-year-old African American male patient who was admitted 2 days ago in an agitated state following an altercation with his mother. Cholinesterase inhibitor e. Selective serotonin reuptake inhibitor View Answer 8. No abnormalities were detected on neurologic evaluation. While on call. On examination. and is unable to follow your finger when you attempt to test his eye movements..20Folder/Blueprints%20Psychiatry/Questions. You are the psychiatry resident on the inpatient psychotic disorders unit of a busy teaching hospital. Anticholinergic agent c. has no prior history of treatment with psychotropic medications. In addition. the patient appears acutely distressed.Ovid: Blueprints Psychiatry e. Coadministering haloperidol with which of the following classes of medication might have prevented this reaction? a. Vital signs are stable but for sinus tachycardia of 100 beats per minute. A 26-year-old woman presents with multiple complaints. β-adrenergic antagonist d. She has been followed in a pain clinic for file:///C|/Documents%20and%20Settings/ASUS/My%.

20Folder/Blueprints%20Psychiatry/Questions. The parents report that they have witnessed the child sit up in bed with a frightened expression and scream loudly. A 5-year-old boy is brought to your office because of problems sleeping. Stage 0 b. Hypochondriasis e. Stage 2 c. Stage 1 file:///C|/Documents%20and%20Settings/ASUS/My%. He appears awake and intensely frightened but then falls back asleep and has no memory of the event. She further reports a long history of difficulty swallowing and numerous dietary restrictions. This presentation is most consistent with which of the following? a. lower back. Pain disorder d. This disturbance most likely occurs during what phase of sleep? a.Ovid: Blueprints Psychiatry management of pain in her neck.htm (6 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Body dysmorphic disorder View Answer 9. knees. Conversion disorder c.. She has been evaluated by an orthopaedic surgeon. and head. REM e. but no underlying etiology could be identified. Somatization disorder b. Delta d.. She reports that she has been unable to attain orgasm for several years.

20Folder/Blueprints%20Psychiatry/Questions. She was recently switched to a new antipsychotic medication with rapid dosage titration by her outpatient psychiatrist. A 45-year-old male patient with a long history of schizophrenia is involuntarily committed to the state psychiatric hospital because he is experiencing command auditory hallucinations urging him to kill his mother. and rigid. Platelet count View Answer 11. she did not respond to any questions. LDL cholesterol e. A few days later. which of the following laboratory values was most likely to be grossly elevated? a. The patient appeared febrile. when the maximum ambient temperature was approximately 101°F. Glucose c.htm (7 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Although the patient opened her eyes when the case manager shook her gently. A 50-year-old single female patient with schizoaffective disorder lives independently in an apartment with the assistance of case management services. The patient's case manager paid her a home visit after the patient failed to answer the telephone. During the patient's subsequent hospitalization in the ICU. INR P. sweating.119 d.Ovid: Blueprints Psychiatry View Answer 10. and the case manager telephoned immediately for an ambulance. file:///C|/Documents%20and%20Settings/ASUS/My%... The case manager let herself into the apartment when the patient failed to answer the door and was shocked to find the patient lying face down on the living room floor. Creatine kinase b. her air conditioner quit working during the summertime.

you notice that she is mildly obese. Which of the following aspects of capacity is the patient unable to demonstrate? a. Potassium e.Ovid: Blueprints Psychiatry who he believes is an agent of the devil.. Deciding on a choice d. You are working as the ER resident in a large tertiary referral center. you recommend a treatment plan in which you suggest starting back on an antipsychotic medication. Calcium b.20Folder/Blueprints%20Psychiatry/Questions. When you assess him in your capacity as the on-call attending psychiatrist.htm (8 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Communicating a choice c. Understanding the information you have communicated View Answer 12. Sodium file:///C|/Documents%20and%20Settings/ASUS/My%. Reasoning about treatment options e. Phosphate d. The cardiac monitor shows that she is in pulseless electrical activity. Appreciating the nature of his illness b. A reduced plasma level of which of the following electrolytes is likely to have led to this patient's cardiac arrest? a. The patient refuses medication. Emergency medical personnel bring a young female patient in cardiac arrest to the ER. and a positive Russell's sign (callus on the back of her hand). Magnesium c.. As you work to resuscitate her. angrily stating that he does not have a mental illness. swollen parotid glands. has dry skin.

. In determining her treatment plan. Family therapy e.Ovid: Blueprints Psychiatry View Answer 13. The symptoms develop over about 10 minutes in situations where she feels trapped. Cognitive behavioral therapy b. Dialectical behavioral therapy c. or engage in her normal social events. Exposure therapy d. You begin by teaching relaxation exercises and desensitization combined with education aimed at helping the patient understand that her panic attacks are the result of misinterpreting bodily sensations. which of the following psychotherapeutic modalities has the greatest evidence base? a. What is the name of this technique? file:///C|/Documents%20and%20Settings/ASUS/My%..htm (9 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . A 24-year-old female student presents to your office complaining of the recent onset of low mood and poor concentration. fear of losing control. The patient has been largely disabled by the symptoms. sensation of choking. trembling. precipitated by increasing difficulty in managing her college courses. She has been unable to pick up her children at school. mild. Long-term psychodynamic psychotherapy View Answer 14. You are an outpatient psychiatrist practicing at the student health center of a small college campus. you diagnose her with major depressive disorder.20Folder/Blueprints%20Psychiatry/Questions. and fear of dying. derealization. A 45-year-old woman presents with a 1-year history of the following symptoms: sweating. lightheadedness. go shopping. She would like to avoid using any type of medication. single episode. chest discomfort. The patient indicates that she would prefer to avoid treatment with medications if at all possible. After completing a history and physical and ordering appropriate laboratory work.

Ovid: Blueprints Psychiatry a. Alprazolam b. Psychodynamic therapy c. Imipramine d. She has been reading about the disorder and has some familiarity with its pharmacologic management.. Classical conditioning View Answer 15. you choose a medication that acts as an agonist at the GABA receptor. She now requests psychopharmacologic management. Cognitive-behavioral therapy e. Mirtazapine c. Paroxetine e.0Folder/Blueprints%20Psychiatry/Questions. the file:///C|/Documents%20and%20Settings/ASUS/My. A 22-year-old woman with a prior diagnosis of bulimia nervosa presents to the emergency room during her college exam period with an irregular heartbeat.. Of the appropriate medications. Biofeedback therapy d. Which of the following medications meet these criteria? a. She has been treated with sertraline and states that she has been taking it as prescribed. The patient described in Question 14 becomes impatient with the progress of her psychotherapy. On examination. Phenelzine View Answer 16.htm (10 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . The patient is weighed and found to be at her ideal weight. Exposure therapy b.

Hyperkalemia c.0Folder/Blueprints%20Psychiatry/Questions. The electrocardiogram demonstrates a flattening of the T waves with development of U waves. Binding to the acetylcholine postsynaptic receptor b.120 the effectiveness of acetylcholine transmission in the remaining neurons. Irreversibly binding acetylcholinesterase c. What is the mechanism by which donepezil and tacrine achieve this? a. Some of the cognitive deficits in Alzheimer's disease are caused by loss of cholinergic neurons in the basal forebrain that project to the cerebral cortex and hippocampus.. Acting as a postsynaptic agonist file:///C|/Documents%20and%20Settings/ASUS/My. Hypocalcemia e. Presynaptically blocking reuptake of acetylcholine d.. Esophageal rupture View Answer 17.Ovid: Blueprints Psychiatry patient is noted to have a callus on the second joint of the right index finger. One of the current mainstays of therapy is to increase P. Hypercalcemia d. What is the most likely finding? a. Hypokalemia b.htm (11 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Reversibly inhibiting acetylcholinesterase e.

Ovid: Blueprints Psychiatry View Answer 18. She is lethargic and disoriented upon arrival and gradually becomes more alert during your assessment. A staff member from the group home tells you that the patient has been under stress lately and has been drinking a large amount of diet cola. She begins to cry and then suddenly gets angry when you ask whether the nurse took her vitals. and escitalopram 20 mg qd. A 24-year-old woman presents for a routine physical examination. Her blood pressure is elevated at 195/95 mm Hg.htm (12 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . She is staring down at the floor when you arrive. What is the most likely diagnosis? a.0Folder/Blueprints%20Psychiatry/Questions. She tells you that she does not remember what happened. Clozapine toxicity c. lithium 500 mg tid. Serotonin syndrome View Answer 19. She says. “I was having such a nice conversation with her. Her chest radiograph is normal. glycopyrrolate (Robinul) 2 mg qhs. A 48-year-old woman who lives in a state-supported group home presents to the emergency department after having a witnessed grand mal seizure shortly after dinner. Syndrome of inappropriate antidiuretic hormone secretion b. and her respiratory rate is 15 breaths per minute. A basic electrolyte laboratory panel reveals a serum sodium of 119 mmol/L. and then she file:///C|/Documents%20and%20Settings/ASUS/My. you begin to review her medical history. Apologizing. Her medicines include clozapine 500 mg qhs. You are running late and have kept her waiting for 40 minutes alone in the examination room. Primary polydipsia e. She does not smoke.. Her heart rate is 90 beats per minute.. Hypertensive encephalopathy d.

He arrives for the appointment 15 minutes late and looks annoyed with you. “I did them. She tells you that her boyfriend of 2 months left her abruptly last month. and she has not been able to stop crying. sleep disturbance. You query her about neurovegetative symptoms (such as depressed mood. You are asked to evaluate him for the presence of a mental illness that could be affecting his performance. From your recollections from your own psychiatric training in medical school. Borderline personality disorder d.” You explain that there are many other patients in your primary care office today and that she had to go and see other patients. Sensing that she is still having difficulties. Sexual masochism View Answer 20.0Folder/Blueprints%20Psychiatry/Questions.htm (13 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . and you begin examining her.. some of which appear old and some more recent. She clearly brightens in response to your attention to her feelings. impaired concentration or decision making. “It makes the pain bearable. Generalized anxiety disorder e. Major depression c. and her eyes avert to the floor again. appetite change or weight loss or gain. worthlessness or guilt.. thoughts of death or suicide). You ask how she got them. fatigue or low energy. and she endorses some symptoms but not enough to diagnose major depression.” You finish her examination and refer her to a colleague for a psychiatric consultation.” she states.Ovid: Blueprints Psychiatry just left and never returned. She has numerous scratch marks on her upper thighs. decreased interests or pleasure. you ask her what is going on in her life. A 45-year-old divorced man is referred to you from his company's employee assistance program because he is on probation at his job. You explain to him that his evaluation is confidential but that if there is information that he would like shared with file:///C|/Documents%20and%20Settings/ASUS/My. you suspect she will be diagnosed with: a. Narcissistic personality disorder b. psychomotor agitation or retardation.

htm (14 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . You are asked by the nurse at your clinic to conduct a home visit on a reclusive 47-year-old woman who has been unable to come in for an appointment for the last 3 years. grandiose subtype c. He denies neurovegetative signs of depression and exhibits no manic signs or symptoms. He noticeably calms and then confesses that he really does not have any talents and begins to cry.” You explain that you were curious about the nature of his talents. In each situation. Her daughter agrees to meet you at the home the next morning. appearing humiliated and then snaps back at you. “What do you know about business leadership? You're a doctor. he should be the boss. You listen and talk some more and then complete your evaluation. he describes feeling as if he could have led the organization better and that. You ask more about what P. He is surprised when you ask what qualities he has that he thinks sets him apart. you could provide such information. Borderline personality disorder d. She shows you into the house where you find the patient sitting in a house dress in a reclining chair in her living room. She tells you that she has not left the house in 3 years “because it is too scary out there. Schizoid personality disorder b. He blushes a bit..Ovid: Blueprints Psychiatry his employer to help provide accommodations.” gesturing toward the street.121 file:///C|/Documents%20and%20Settings/ASUS/My. Dependent personality disorder View Answer 21.0Folder/Blueprints%20Psychiatry/Questions. He goes on to explain that he has been fired from or left several jobs in the past because his coworkers failed to recognize his unique talents. in fact. Narcissistic personality disorder e. What is the most likely diagnosis? a. Delusional disorder..

but then his personality began to change.Ovid: Blueprints Psychiatry happened 3 years ago. but she just can't bring herself to go out again. she has had many more such attacks.0Folder/Blueprints%20Psychiatry/Questions. A 9-year-old boy is brought into the emergency department by his distraught parents after he tried to attack his mother with a kitchen knife. talking loudly. It lasted approximately 15 minutes but caused her to run out of the mall and back to the safety of her car. She says that she likes having people visit her. She recounts that she was out at a shopping center when she suddenly had the abrupt onset of a severe wave of anxiety. Where file:///C|/Documents%20and%20Settings/ASUS/My. but the parents called the police who suggested an emergency evaluation after observing the boy's demeanor. and swearing. Arachnophobia e. It seemed to help at first. The parents explain to you that their son seemed to develop attention-deficit disorder a few months ago and was prescribed a dextroamphetamine-containing medication by his pediatrician.htm (15 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . She has refused to leave her home for the last 2 1/2 years. Major depression b. and she spent the rest of her life at home. His mother was unharmed. She said that the same thing happened to her mother.. Since then. She asks you if you understand what is going on with her and can you fix it? You tell her that you have seen this before and can recommend the right kinds of treatment.. He was verbally aggressive and pacing. Panic disorder c. The police escorted them to the emergency department where the boy was restrained and medicated acutely with a combination of emergency sedatives. She has the attacks sometimes at home and has not sought treatment for them. The primary condition is: a. Generalized anxiety disorder d. Obsessive-compulsive disorder View Answer 22.

she plays actively with her two sisters and talks normally. bright. The patient's father has bipolar disorder. Start group therapy e.Ovid: Blueprints Psychiatry before he was an affable. Start lithium therapy c. she does not speak spontaneously and will only speak when spoken to directly by her teacher. He attacked his mother after she made a new dish with which he was unfamiliar. and his mother had attention-deficit/hyperactivity disorder as a child. Posttraumatic stress disorder file:///C|/Documents%20and%20Settings/ASUS/My. and sleepless.0Folder/Blueprints%20Psychiatry/Questions. he became increasingly wary.. An 8-year-old girl presents for a pediatric visit because her teacher has raised concerns about her lack of talking at school. agitated. The situation worsened recently when he started accusing his mother of putting poison in his food. When she is at home. When she is at school. Start citalopram therapy b. The best next step would be to hospitalize the patient and: a. however. His maternal uncle has schizophrenia. Major depression b. What do you tell the mother her daughter suffers from? a. athletic boy.htm (16 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ .. She also describes her daughter as having achieved all developmental milestones at appropriate ages. Her mother tells you that her daughter talks all the time at home and has many interests and activities. Discontinue dextroamphetamine therapy View Answer 23. Start aripiprazole therapy d. as she does not reciprocate social interactions with her peers. She is having difficulty socially.

make a diagnosis. dilated pupils.. the patient is noted to have a runny nose. piloerection. The best emergency treatment for this patient is: a. Acamprosate e.. mild fever. Alprazolam g. Naloxone f. Flumazenil b. and prescribe treatment for this patient. A 27-year-old nurse appears in a private physician's office complaining of recurrent back pain. Physostigmine c. The patient reports that she has previously used oxycodone for her back pain for brief periods but has not used any pain relievers for several months.htm (17 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Clonidine d. Autism d. Selective mutism e. Glucose file:///C|/Documents%20and%20Settings/ASUS/My. you are the emergency ward attending physician when the patient is brought in by ambulance.” You obtain an additional laboratory test.0Folder/Blueprints%20Psychiatry/Questions. she is unconscious with very slow respirations and mild perioral cyanosis. She states that she has back problems “about twice a year. Abulia View Answer 24.Ovid: Blueprints Psychiatry c. A week later. and mild tachycardia. Thiamine h. On examination.

Autistic disorder. They are: a. is educable but will need extra support P.0Folder/Blueprints%20Psychiatry/Questions. The child had not started school in his country.. will need institutional care b. He has developed physically but has been slow in his development of language skills and has extreme difficulty following instructions.Ovid: Blueprints Psychiatry View Answer 25.htm (18 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . and his parents have been alarmed by his failure to reach developmental milestones. The head CT reveals a subdural hematoma that appears to be less than a week old. She had been previously doing well until she was left at home with her daughter's husband for a week while the daughter was away on business. You refer him for neuropsychological testing and the results reveal an IQ of 62. Mild mental retardation. You find him in good physical shape and note that he makes good eye contact with you but appears confused by what you are trying to do. You examine her and order a head CT.. There is also soft tissue swelling over her cranium file:///C|/Documents%20and%20Settings/ASUS/My. you tell the parents his diagnosis and prognosis. He also cries and reaches for his mother several times when you are trying to examine him. Moderate mental retardation View Answer 26.122 c. An 88-year-old woman is brought into the emergency room by her daughter because of a change in her mental status. will need special education d. A 4-year-old boy whose family recently emigrated from another country is brought in by his parents for an initial visit with the pediatrician. will be able to function with support e. Severe mental retardation. Upon your next visit. Asperger's syndrome.

Pull the husband out of the room and confront him c.Ovid: Blueprints Psychiatry and around her jaw. She tells you that she fell out of bed and landed on her face.htm (19 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Call social services for a consult c. You obtain a surgical consult. You suspect spousal abuse. Before you enter the room.. Refer her back to her primary care physician and send her home View Answer 27. Call the son-in-law at home and confront him d. After consulting a neurosurgeon about the need for subdural drainage. He says. Call the police to arrest the husband b. and after the patient is evaluated. Call the local police to have the daughter arrested e. She and her husband both smell of alcohol but do not appear intoxicated. The best next step would be to: a. You suspect elder abuse and order a radiograph series looking for other fractures. Call the patient's home to see if anyone there knows what happened e. The radiograph series reveals several recent fractures of the ribs and long bones of her body. you overhear the husband speaking in a threatening tone to his wife. you louse!” When you enter the room. you check in with her again. A 39-year-old woman walks into the emergency department with a broken nose.. he appears startled and she appears frightened. the next best step is to: a. Try to separate the couple and talk to the woman alone d.0Folder/Blueprints%20Psychiatry/Questions. Ask the couple more about how she fell out of the bed file:///C|/Documents%20and%20Settings/ASUS/My. “You deserved it this time. Call the risk management officer for the hospital b.

He has a core temperature of 101°F. You proceed to complete a suicide risk assessment. Neuroleptic malignant syndrome c. and you move him to the intensive care unit.000 units per liter. You are a volunteer manning a mental health crisis hotline. and responds to deep tissue pain.htm (20 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Serotonin syndrome b. In it. African American race file:///C|/Documents%20and%20Settings/ASUS/My. trazodone. You order a complete metabolic serum panel. Tardive dyskinesia e. fluoxetine. you find mention that the patient was taking olanzapine. a blood pressure of 200/110 mm Hg.” You notice that his voice sounds sad and flat. but little else. A 28-year-old man from the local state hospital is brought into the emergency department mute and in a rigid posture. haloperidol. Late one evening.Ovid: Blueprints Psychiatry View Answer 28. Dystonia d.0Folder/Blueprints%20Psychiatry/Questions... His creatine phosphokinase comes back severely elevated at 110. Which of the following is a risk factor for suicide? a. Further history reveals that his wife died 1 year ago today. The most likely diagnosis is: a. Pneumonia View Answer 29. and valproic acid. His blood pressure becomes unstable. heart rate of 128 beats per minute. you receive a call from an unidentified male located in the rural counties who tells you that he “just needed someone to talk to. is able to move all four extremities distally and proximally. You obtain an old discharge summary from a surgical admission from 2 years ago for appendicitis.

On examination.. Full-time employment d.Ovid: Blueprints Psychiatry b. A 27-year-old female patient presents to the emergency department complaining of the recent onset of tremor and diarrhea. file:///C|/Documents%20and%20Settings/ASUS/My. Haloperidol b. Dependent children in the home c. On the Mini-Mental state exam. he is not oriented to time.. Her gait is ataxic. he appears disheveled and smells faintly of alcohol. Lithium d.0Folder/Blueprints%20Psychiatry/Questions. Strong religious faith View Answer 30.htm (21 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . He does not exhibit nystagmus or ataxia. Male gender e. Lamotrigine c. but she recently doubled the dose because it did not seem to be working. This medication is most likely to be: a. She reports that her outpatient psychiatrist started her on a new medication for bipolar disorder 2 weeks ago. she is oriented to place and person but not to time and exhibits impairment in short-term memory. On examination. A homeless man is brought to the emergency department by the police in response to reports that he has been wandering the streets in a confused state. Valproic acid View Answer 31. and she exhibits a coarse bilateral tremor. Carbamazepine e.

. There is a family history of early-onset dementia. she is now exhibiting poor hygiene and disinhibited behavior such as striking her husband when she does “not get her own way. He is very talkative with marked anterograde amnesia and makes a variety of flamboyant and widely varying claims about how he came to be in the emergency department today. but MRI of the brain reveals significant atrophy in the frontal and anterior temporal lobes.htm (22 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . He reports that she has undergone a significant change in personality over the last 12 months. or person. Thiamine e. What is the most likely diagnosis? a. Niacin P. her husband reveals that the other day. This presentation is caused by deficiency of which of the following vitamins? a. including meeting with an old drinking buddy in the residents' quarters. Vitamin E View Answer 32. Previously. she attempted to masturbate in public.123 d. B12 b. prompting the visit to your clinic today. Folate c.” With significant embarrassment. A 53-year-old married female presents to your primary care clinic accompanied by her concerned husband. Your laboratory workup is unremarkable. Alzheimer's disease file:///C|/Documents%20and%20Settings/ASUS/My.0Folder/Blueprints%20Psychiatry/Questions.Ovid: Blueprints Psychiatry place. The patient scores 24 out of 30 on Mini-Mental state examination.. a meticulously groomed woman who was actively involved in church and charity work.

He is sedated and intubated by the medical team for agitation and respiratory depression. A 22-year-old man presents to your office pacing and speaking rapidly. Flumazenil b. Valproic acid View Answer 34.htm (23 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . A 36-year-old male patient with a history of sedative-hypnotic dependence is admitted to the ICU after being found down at home by his mother with an empty bottle of alprazolam pills at his bedside. When you enter the room.. After gathering more history from his family. Gabapentin e. He asks you what he should wear when he wins the Nobel Prize for medicine. He describes no longer needing sleep. Fluoxetine c. he is extubated. you decide that he is acutely manic. and file:///C|/Documents%20and%20Settings/ASUS/My. Acamprosate d. She asks you to see him immediately.Ovid: Blueprints Psychiatry b. The following day. Pick's disease e. HIV-related dementia c. Vascular dementia View Answer 33.. and spending money on expensive clothes for his new career. mastering speed reading. Huntington's disease d. he jumps up and starts rambling about going to medical school and being especially gifted.0Folder/Blueprints%20Psychiatry/Questions. Your nurse tries to get him to calm down and wait for you but is unable. The medication most likely to help his condition is: a.

0Folder/Blueprints%20Psychiatry/Questions. Which of the following medications is the best choice in management of this patient? a. leans forward. You are aware that you feel quite uncomfortable in her presence because of her seductiveness. a tight low-cut pink top. Although it is 10:00 AM. Antisocial file:///C|/Documents%20and%20Settings/ASUS/My. you note that they were within normal limits until 2 hours ago. Reviewing his vital signs. Methadone d.htm (24 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Although she reports that she has many friends. and proceeds to tell you all about her vibrant social life in a highly dramatic and overfamiliar manner. but you note that he appears to be diaphoretic and observe a coarse tremor of his forearms. when the patient's pulse increased to 120 beats per minute and his blood pressure increased to 150/100. He fails to cooperate with your efforts to interview him. On examination.. and is wearing full makeup. you find the patient pacing around his room swearing at the nursing staff and threatening to leave the hospital. Buprenorphine b. She sits down with ease. she is dressed in black leather pants. Clonidine c.Ovid: Blueprints Psychiatry you are consulted urgently for assessment of agitation. Phenobarbital e. A 32-year-old single female presents to your family practice office for an initial visit. You suspect the presence of which of the following personality disorders? a. you notice that she appears to include brief acquaintances such as the mailman among her confidants. Propranolol View Answer 35..

she worries that he sits for hours rocking back and forth. Two days after admission. Schizoid View Answer 36. He failed to respond when smiled at. He doesn't play with other children and overall shows little interest in his external world.. she noted that her child did not seem to respond to her attempts to communicate with him. had almost no facial expressions.Ovid: Blueprints Psychiatry b. Avoidant c.. Dependent d. He didn't babble or begin talking like other children his age but used only occasional odd-sounding phrases in a repetitive fashion. In addition. A 69-year-old widowed female patient is admitted to the cardiac surgery service after developing an infection of her sternotomy site following a coronary artery bypass graft. The most likely diagnosis is: a.” She notes specifically that her pregnancy and delivery were uncomplicated. Autistic disorder b. Attention-deficit disorder e. A 3-year-old boy is evaluated in the pediatric general practice clinic because his mother thinks he's “too quiet.htm (25 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ .0Folder/Blueprints%20Psychiatry/Questions. Separation-anxiety disorder View Answer 37. Histrionic e. Childhood-onset schizophrenia c. Conduct disorder d. A few months after birth. and didn't maintain eye contact. the nursing file:///C|/Documents%20and%20Settings/ASUS/My.

The patient reports that she has been progressively more depressed during the past month. Which of the following is the most likely diagnosis? a. She states that the patient has been saying she would be better off dead and that life isn't worth living. 3 weeks ago. A week prior to file:///C|/Documents%20and%20Settings/ASUS/My. On assessment. and cannot recall a list of three items at 5 minutes.0Folder/Blueprints%20Psychiatry/Questions. Dementia c.” The sister reports that the patient has been depressed for a very long time and has been undergoing serious stress.. Dissociative amnesia d. Delirium b. Major depressive disorder e. She recounts a stressor of losing her job 1 month ago because of cutbacks. she ended a long-term romantic relationship of 5 years after a great deal of anger and turmoil.Ovid: Blueprints Psychiatry staff expresses concern because she appears to be intermittently confused. The primary team urgently consults you in your capacity as the on-call hospital psychiatrist when the patient is observed to be acutely agitated and trying to call the police because she believes that there are burglars in her room. but she believes they let her go because she wasn't performing well. Schizophrenia View Answer 38. disoriented as to time and place.htm (26 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . you find an anxious elderly female who is inattentive to your questions. A 48-year-old woman is interviewed in the emergency department after her sister brought her in because she was afraid the patient might “do something crazy..124 particularly at night. P. In addition.

Ovid: Blueprints Psychiatry admission. You make the diagnosis of major depression. His physical examination is normal. She notes that she is hopeless about the future and that she doesn't believe she will ever feel better. She loves her neighborhood but won't be able to afford living there any longer. 2 days later. but you are concerned about the patient's suicide risk.htm (27 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . The most likely antipsychotic agent the patient has been taking is: file:///C|/Documents%20and%20Settings/ASUS/My.. Neurovegetative symptoms c. but then the patient forgot his first follow-up appointment. His psychiatrist started him on a new medication. You counsel him on smoking cessation and order a routine complete blood count. You ask that the patient be brought into your office for re-evaluation and page his psychiatrist. A 24-year-old man with a history of schizoaffective disorder presents in your primary care office with his mother for a routine physical examination.9. Loss of her job e.0Folder/Blueprints%20Psychiatry/Questions. In addition. Hopelessness View Answer 39. you notice that his white blood count came back at a low 1.. She reports that she has felt seriously depressed for at least 1 month and has had marked neurovegetative symptoms of depression. He tells you that he was recently hospitalized for the fourth time in the last year for paranoia. Loss of a romantic relationship d. she reports a profound sense of anhedonia and spends her days lying in bed without eating or showering. she learned that her previously rent-controlled apartment where she had lived for many years was being sold and that she would have to move. Then. She is vague when directly questioned about suicidality. Major depression b. The most important risk factor for suicide in this patient is: a.

Schizotypal personality disorder d. The most likely diagnosis is: a. he appears to have a normal intellect.htm (28 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Aripiprazole c.. He denies any self-destructive or impulsive behaviors. Personality disorder file:///C|/Documents%20and%20Settings/ASUS/My. Quetiapine e.” When you speak with him alone. Clozapine d. Borderline personality disorder b. Risperidone b. no magical or odd thinking. His mother had to convince him to go to the appointment because he had trouble deciding to see a physician. Thioridazine View Answer 40.Ovid: Blueprints Psychiatry a.” He says. and a stable sense of self but reveals a desperate fear that his mother will abandon him. Dependent personality disorder c.. and he has lived with his mother since that time. A 39-year-old man visits a new primary care physician for a first visit at the urging of his mother. Narcissistic personality disorder e. The truth is. “People think I'm too clingy. His father died when he was 14. I just want people to care about me. He denies symptoms of depression except for occasional low mood.0Folder/Blueprints%20Psychiatry/Questions. His mother accompanies him on the visit and relays that she often decides things for him because he has “never been able to think for himself. He works as a computer programmer and says that he has many acquaintances but few friends and no romantic relationships.

Ovid: Blueprints Psychiatry View Answer 41. A 27-year-old woman is brought to the emergency department by the local police because she has been harassing her neighbors. The police report states that the young woman's apartment manager called because she was banging on all her neighbors' doors and screaming in the stairwell. she has seemed increasingly odd.125 and wearing several layers of dirty clothes. she had abruptly ended a long-term romantic relationship for no particular reason. the young woman is disheveled P. and production. revealing an alien conspiracy. In addition. Schizophrenia file:///C|/Documents%20and%20Settings/ASUS/My. She states that she left her job to monitor these hidden transmissions full time and that she has been hiding in her apartment because they know she is on to them.0Folder/Blueprints%20Psychiatry/Questions. She reports that she has been eating and sleeping well and that her mood is good. The windows were sealed and covered with dark curtains. disassociated herself from family activities.. complete blood count. and brain MRI are all normal. She is conversant and explains that she has been defending herself against aliens who want to use her as a specimen. The patient's family reports that for the past year or so. and gave up a well-paying job as a computer system administrator. chemistry panel. volume. She denies substance use or any medical symptoms. with rotting garbage and food in the kitchen. She appears wary and guarded. Her family arrives shortly afterward and appears very concerned. On mental status examination. Upon examining the patient's apartment. including drug screen. Diagnostic testing. all turned on at the same time. the police found the place to be filthy and malodorous. Her speech is normal in rate..htm (29 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . The most likely diagnosis is: a. and there were several televisions and computers in the living room. She believes that she began picking up on hidden transmissions in her e-mail at work. She ended her recent relationships because she felt that the aliens would harm the people she cared about. perhaps involving the CIA. She denies hearing voices.

Alcohol abuse e. or psychotic symptoms. He exhibits no grandiosity. assault. Bipolar disorder c. and rape. Conduct disorder b. Major depression d. Cyclothymic disorder d. When you ask him about his other criminal history. Paranoid personality disorder View Answer 42. expansive... Family history is significant for alcohol dependence in his father and mother and for no history of bipolar disorder.htm (30 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . He has never been psychiatrically hospitalized and denies any episodes of elevated. He has had suicidal ideation but has not made suicide attempts or been self-destructive. drunk driving. Posttraumatic stress disorder c. Bipolar disorder file:///C|/Documents%20and%20Settings/ASUS/My. The most likely diagnosis is: a. he relays numerous arrests and some convictions for theft. pressured speech.0Folder/Blueprints%20Psychiatry/Questions. He calmly reports that his father and subsequent foster parents often beat him with straps or boards when he was a child. Penal records indicate a persistent pattern of lying and theft while incarcerated and that he exhibits no remorse when caught by authorities.Ovid: Blueprints Psychiatry b. A 35-year-old man is seen in a prison clinic for a routine physical examination. He tells you that he is in jail for murdering two people in a botched robbery attempt. or fluctuating mood. He was knocked unconscious on several occasions but has no history of seizures and denies nightmares or flashbacks from the abuse.

A 15-year-old boy is brought to his pediatrician's office because his parents are embarrassed by his behavior.Ovid: Blueprints Psychiatry e. A 19-year-old man is seen on rounds on a psychiatric unit after being admitted two nights before. His parents believe he is punishing them for setting limits on television and file:///C|/Documents%20and%20Settings/ASUS/My. Antisocial personality disorder View Answer 43. Although he appears agitated. Tardive dyskinesia View Answer 44. his psychotic symptoms. He was diagnosed with psychotic disorder.. The most likely diagnosis is: a. Vital signs are within normal limits and he is afebrile.0Folder/Blueprints%20Psychiatry/Questions. do not appear to have worsened since admission.htm (31 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . not otherwise specified and begun on risperidone 1 mg twice per day. which include hallucinations and delusions. Neuroleptic malignant syndrome e. Dystonia b. Other than pacing.” When you enter his room. Akathisia d. They report that he has been intermittently barking and yelping repetitively during conversations. He tells you that he feels restless and that he has to keep moving to feel better. The nurse asked you to see him first because he had been “agitated all morning. you find him pacing the floor. In addition. Parkinsonism c.. he is not exhibiting any tremors or other movements of the extremities. This behavior persists in public and at school. A serum creatine phosphokinase is drawn and is normal. he has periods of bizarre body posturing with jerky upper extremity movements and snorts like a horse.

The most likely diagnosis is: a. oxcarbazepine 300 mg each morning and 900 mg each evening.0Folder/Blueprints%20Psychiatry/Questions. His medications are fluoxetine 40 mg per day. Adolescent rebellion b. respiratory rate is 14 breaths per minute. and diarrhea. Lithium toxicity b. lithium carbonate 300 mg each morning and 600 mg each evening.” The most likely reason for the young man's behavior is: a. He denies having used any illicit drugs.Ovid: Blueprints Psychiatry social time with his friends. blood pressure is 98/60 mm Hg.7°F. A 41-year-old man with a 21-year history of bipolar disorder comes to the emergency department with ataxia. The young man denies any retaliation against his parents. his heart rate is 100 and regular.. He is upset about his behaviors and feels like a “freak.htm (32 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . coarse tremor of his upper extremities. Substance abuse d. Schizophrenia c.5 mg each evening.. Fluoxetine toxicity file:///C|/Documents%20and%20Settings/ASUS/My. He states that he develops a powerful urge to bark and yelp and that other times he finds himself moving uncontrollably. On examination. Tourette's disorder e. and temperature is 98. and lorazepam 1 mg per day. Conduct disorder View Answer 45. confusion. He reports that he has been sweating a great deal because it is “so hot outside” and that he gets “no relief” at home because his halfway house is not air-conditioned. olanzapine 7. Lorazepam toxicity c.

On examination. the next step in properly evaluating this patient is: a. the patient is vague and guarded. Winter depression c..0Folder/Blueprints%20Psychiatry/Questions. He provides a history that he was not suicidal and that he accidentally shot himself while cleaning the gun. incoherent speech. and rapid. Serotonin syndrome View Answer P.htm (33 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . The most likely diagnosis is: a. Oxcarbazepine toxicity e. At this point. he has auditory hallucinations. Schizophreniform disorder b. agitation.. On examination. The patient is conscious but sedated following surgical intervention. Atypical depression e. A 23-year-old man is psychiatrically evaluated in the surgical intensive care unit after sustaining a self-inflicted gunshot wound to the abdomen. To accept the patient's assertion that the event was accidental file:///C|/Documents%20and%20Settings/ASUS/My. An 18-year-old college student is brought to the emergency room by the campus police because he has created a disturbance on campus. Substance abuse history is unknown. Generalized anxiety disorder d. Obsessive-compulsive disorder View Answer 47.Ovid: Blueprints Psychiatry d. The length of time that he has had the symptoms is unknown.126 46. He admits to drinking a few beers before the incident.

You prescribe a selective serotonin-reuptake inhibitor antidepressant for a patient suffering from major depression requiring an inpatient psychiatric admission. and 2 days later. friends. Accept the patient's assertions that the gunshot was accidental b. To obtain a thyroid-stimulating hormone level d. To refer the patient to Alcoholics Anonymous e.0Folder/Blueprints%20Psychiatry/Questions.. Based on the additional history. To obtain a head CT c. but he had drunk to the point of intoxication at least twice in the past week. The file:///C|/Documents%20and%20Settings/ASUS/My. Initiate pharmacological treatment with an antidepressant medication View Answer 49. Keep your findings secret from the patient so as not to provoke anger at his friends and family e. To obtain additional history from the patient and family. Additional history obtained from a close friend reveals that the patient in the previous question had been despondent over a romantic breakup and worsening performance in college. or witnesses to the event View Answer 48.. The patient did not ingest alcohol routinely. Discuss the patient's alcohol abuse with the patient d.Ovid: Blueprints Psychiatry b.htm (34 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . The patient's family reported that he had been avoiding them over the past few days. she appears markedly anxious. it seems reasonable to: a. Discuss your findings with the patient and explain that you are concerned about the possibility of a suicide attempt c.

” Upon reviewing his chart. Medication-induced akathisia c. Dementia file:///C|/Documents%20and%20Settings/ASUS/My. bouncing her legs up and down during your interview. On examination. Serotonin syndrome e. he developed an upper respiratory infection and was treated with an antibiotic. The most likely diagnosis is: a.Ovid: Blueprints Psychiatry nursing staff is very concerned. 3 days ago. The staff reports that he has been progressively sedated and confused for the past 24 hours. he is conscious but is confused and dysarthric.0Folder/Blueprints%20Psychiatry/Questions. “I think the doctors are trying to kill me. He states. you note that he was admitted 1 week prior and was restarted on his usual dose of carbamazepine because of a low level. the patient is agitated and pacing. and is unable to focus on the conversation. Neuroleptic malignant syndrome b.. She notes that she doesn't know what is happening. but that she just can't sit still. Generalized anxiety disorder d. feeling like she has to move her legs around. Malingering b. Then. His last carbamazepine level was measured 3 days ago.. suggesting the patient may need additional sedation. Caffeine intoxication View Answer 50. You conduct a thorough physical and review of systems to assure yourself that the patient did not suffer a syncopal episode and wasn't injured when he fell. The most likely diagnosis is: a. A 53-year-old man admitted to the inpatient psychiatric unit for treatment of bipolar disorder is found lying in the hallway. On your examination.htm (35 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ .

127 file:///C|/Documents%20and%20Settings/ASUS/My.. Drug toxicity d. Undifferentiated e. Disorganized d. The most likely subtype of schizophrenia in this patient is: a. You are asked to see a 27-year-old man who was discharged 2 days ago from a psychiatric hospital.Ovid: Blueprints Psychiatry c. it sounds like possible workplace harassment.0Folder/Blueprints%20Psychiatry/Questions.. You think about referring him to a lawyer when he informs you that his boss is an alien emperor from Jupiter and that his coworkers are the emperor's loyal subjects. Residual View Answer 52. When you ask him to describe the situation more. Other than these unusual beliefs. Progressive upper respiratory infection e. When he first begins to explain the situation.htm (36 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Normal pressure hydrocephalus View Answer 51. he appears normal in terms of dress and body posture. Catatonic c. The nurse P. A 22-year-old man who was recently fired from his job as an auto mechanic presents in the emergency room complaining of a conspiracy against him at his former workplace. he coherently elaborates a richly detailed story about the aliens at the garage and how they conspired to eliminate him. Paranoid b.

Which of the following medications would be most likely to have caused this condition? a. A 43-year-old male is admitted to the hospital for a leg fracture sustained after falling from a ladder while intoxicated with alcohol. Haloperidol View Answer 53.0Folder/Blueprints%20Psychiatry/Questions. Continue his current treatment regimen with downward adjustments in opiate and benzodiazepine dosing as pain and alcohol withdrawal symptoms subside b. Stop opiate pain relievers because he may become addicted to them d. Clozapine e. folate. and benzodiazepines for alcohol withdrawal. He is currently taking opiate pain relievers for leg pain and is receiving thiamine. Benztropine c. Lorazepam b. Add naltrexone to his current treatment regimen to treat alcohol dependence c.. Quetiapine d.htm (37 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Stop benzodiazepines because he may become addicted to them file:///C|/Documents%20and%20Settings/ASUS/My.. Appropriate management at this point would include: a.Ovid: Blueprints Psychiatry reports to you that the patient has developed a hand tremor that looks like he is rolling a pill. He also tells you that the patient is walking very stiffly and appears to be having trouble initiating his movements. He reports a history of daily alcohol use since the age of 9 years except for rare periods of sobriety during brief stints in jail or in hospitals.

He has not required opiate pain relievers or benzodiazepines for the past week. The patient expresses an interest in future treatment options for alcohol dependence. Her energy is greatly improved.htm (38 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ .. The best treatment recommendation would include: a.Ovid: Blueprints Psychiatry e. A 20-year-old woman who presented to your office 1 month ago with postpartum depression returns for follow-up. Naltrexone monotherapy c. and naltrexone b. The patient in the previous question recovers nicely from his fracture and has a successful detoxification from alcohol. Cognitive-behavioral therapy d. Oxazepam monotherapy g. Duloxetine monotherapy f. cognitive-behavioral therapy. Alcoholics Anonymous e. Acamprosate monotherapy View Answer 55. She states that her mood improved shortly after beginning fluoxetine. She is speaking quickly and appears distractible.0Folder/Blueprints%20Psychiatry/Questions.. Alcoholics Anonymous. She states she has cleaned her house several times and is only sleeping 2 to 3 hours each night. Add an antidepressant medication to his current treatment regimen View Answer 54. Increase her fluoxetine file:///C|/Documents%20and%20Settings/ASUS/My. The most appropriate treatment would be: a.

Begin dialectical behavioral therapy e. Providing an appropriate level of information for a patient with mental retardation and schizophrenia b. A 50-year-old mentally retarded patient with schizophrenia presents to the emergency room with airway obstruction. The file:///C|/Documents%20and%20Settings/ASUS/My. Begin a mood stabilizer and stop fluoxetine d. What would be the critical issues regarding informed consent with this patient? a.Ovid: Blueprints Psychiatry b. The patient should be committed e. He has had very little energy despite successful cardiac rehabilitation. Establishing competence in a hypoxic mentally retarded patient with schizophrenia c. On presentation. He has lost 20 pounds during this time. The symptoms are threatening his job and his relationship with his wife.. Schedule electroconvulsive therapy c. He complains of decreased interest and pleasure in his work and hobbies. Emergency personnel ascertain that the patient has an upper airway obstruction and will require an emergency tracheotomy. He also has difficulty falling asleep at night. For the past month.htm (39 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ .. Ensuring that the consent is voluntary d.0Folder/Blueprints%20Psychiatry/Questions. A 45-year-old man presents 3 months after a myocardial infarction he sustained at his place of employment where he works as the head chef. Informed consent is not necessary View Answer 57. he has been having trouble concentrating and remembering his recipes. Begin cognitive-behavioral therapy View Answer 56. the patient is hypoxic.

Selective serotonin-reuptake inhibitor View Answer 58. the patient is alternately seductive and irritable. Electroconvulsive therapy c..128 abuse history. She has been married and divorced three times. Begin antipsychotic medication b. Monoamine oxidase inhibitor e. She has a history of a polysubstance abuse but denies any recent substance P. During the interview. She reports that her parents divorced when she was 4 and that she was raped by her stepfather numerous times from the ages of 6 to 10.htm (40 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . The most appropriate treatment for this patient is: a. She has had more than 60 sexual partners. Inpatient psychiatric admission to a dual-diagnosis unit file:///C|/Documents%20and%20Settings/ASUS/My.Ovid: Blueprints Psychiatry most appropriate agent for initial treatment of this condition would be: a. Lithium d. Electroconvulsive therapy b. She expresses chronic feelings of emptiness.. Tricyclic antidepressant c. Dialectical behavioral therapy d. but she subsequently realized they were total fakes. A 30-year-old woman presents with the chief complaint that everyone always leaves her.0Folder/Blueprints%20Psychiatry/Questions. She states that each husband initially seemed perfect. She reports persistent financial concerns.

He has had psychological testing that demonstrates an above-average IQ and no evidence of learning disability. His mother states that he is very difficult to manage at home. Begin long-term psychodynamic psychotherapy View Answer 59. A 4-year-old boy watches his father use a fork. Regression c. This is an example of: a. Supportive psychotherapy f. An 8-year-old boy is brought to your office for evaluation of difficulties in the home and at school.Ovid: Blueprints Psychiatry e. Modeling file:///C|/Documents%20and%20Settings/ASUS/My. Projection b. Venlafaxine b. Citalopram and cognitive therapy e.0Folder/Blueprints%20Psychiatry/Questions.htm (41 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Atomoxetine and behavioral therapy d. Psychodynamic psychotherapy c. and often speaks out in class without having been called on. Which of the following will be the most appropriate means to manage this boy? a. The child then raises a fork and uses it in a similar fashion to feed himself. frequently forgets his homework. At school. he seems to have difficulties following instructions. Haloperidol View Answer 60...

These issues were followed by the current depressive episode. He became delirious with unstable blood pressure and diaphoresis. he was managed with several doses of intramuscular haloperidol. Operant conditioning View Answer 61. In fact. The patient had been highly combative.Ovid: Blueprints Psychiatry d. fever.. Initially. difficulty concentrating. The patient has been present for three emergency ward shifts. She reports that she was uncharacteristically promiscuous and states that this behavior was followed by a period of irritability. and then seizures.htm (42 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ .. Which of the following agents file:///C|/Documents%20and%20Settings/ASUS/My. she states that she had not needed any sleep. The patient then became increasingly agitated and received high-dose intramuscular ziprasidone. She states that she was doing very well up until 1 week previously. A college student presents with symptoms of depression. and a persistent inability to sleep. Classical conditioning e. Neuroleptic malignant syndrome c.0Folder/Blueprints%20Psychiatry/Questions. Akathisia e. rigidity. Serotonin syndrome b. He has a long history of schizoaffective disorder. What is his likely diagnosis at this time? a. He appeared to respond but then began to demonstrate agitation that was then treated with oral olanzapine. her creativity was at an all-time high. Dystonia d. You have been called to evaluate a patient in the emergency department. Disulfiram-related toxicity View Answer 62. and she was unbelievably productive in her work.

she has been awake for 2 or 3 days with constant talking and activity. Mirtazapine c.. The most common side effect is seizures e. On examination. Bilateral ECT has fewer side effects than unilateral b.htm (43 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . The most appropriate action is: file:///C|/Documents%20and%20Settings/ASUS/My.. talking nonstop and not allowing you to interrupt her. ECT is contraindicated in psychosis View Answer 64. Bilateral ECT is more effective than unilateral c. A patient with treatment-refractory depression has received electroconvulsive therapy (ECT). Which of the following is true of this treatment? a. According to the patient's family. Lithium d. Venlafaxine b. Valium (diazepam) View Answer 63. the patient is agitated. and appears a bit paranoid. Electroconvulsive therapy e. pacing the room. An 85-year-old woman with no prior psychiatric history is evaluated in the emergency department for odd behavior. ECT is indicated only for refractory depression d.0Folder/Blueprints%20Psychiatry/Questions.Ovid: Blueprints Psychiatry would be most appropriate for her maintenance therapy? a.

Ovid: Blueprints Psychiatry a. To treat the patient with an antipsychotic medication for schizophrenia View Answer 65.129 d. A nutritional consult b. The patient denies depression or suicidal thinking and states that he was planning to clean the gun and that he keeps the gun for prowlers. To treat the patient with synthetic thyroid hormone replacement c. Outpatient psychopharmacology referral e. To order a thorough medical and neurological workup e. To treat the patient with an antidepressant medication d. Outpatient psychotherapy referral P.. The first is file:///C|/Documents%20and%20Settings/ASUS/My.htm (44 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . He has lost a great deal of weight and has not been sleeping or grooming himself well. Two elements of the previous patient's history indicate that he is at increased risk for suicide.. The most important initial management for this patient would include: a. A 72-year-old white man presents to the emergency ward after his daughter found him sitting on his bed with a loaded pistol in his hand. Neurological consultation View Answer 66. The patient's daughter reports that he has seemed despondent since his wife died a few months ago.0Folder/Blueprints%20Psychiatry/Questions. Psychiatric hospitalization c. To treat the patient with a mood stabilizer for bipolar disorder b.

Mirtazapine e.. and treatment is initiated with mirtazapine. Poor grooming View Answer 67. A reasonable next step in treating this patient is: file:///C|/Documents%20and%20Settings/ASUS/My. He has severe psychomotor retardation and has little spontaneous speech..htm (45 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry major depression. Buspirone b. Age. race. Weight loss b. Hopelessness d.0Folder/Blueprints%20Psychiatry/Questions. and gender e. Dialectical behavioral psychotherapy c. He continually ruminates about his hopelessness and desire to die. however. Propanolol d. Once hospitalized in a secure setting. Lack of sleep c. he continues to worsen and is unable to eat or drink. The second is: a. Valproate View Answer 68. The patient in Question 67 is admitted to the hospital. appropriate treatment for this patient includes: a.

0Folder/Blueprints%20Psychiatry/Questions. Panic disorder b. Evaluate the patient for electroconvulsive therapy c. Cognitive-behavioral therapy d. paranoid subtype e.htm (46 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . but the police indicate that the man was repeatedly accusing them of working for the National Security Agency and having a plan to “put me away. His speech is quite pressured.. Multivitamins e. disheveled. Attention-deficit/hyperactivity disorder d. Decrease the mirtazapine b. A 22-year-old man is brought to the local emergency ward by the police after being arrested in a grocery store for causing a disturbance. He states. and frightened. Hypothyroidism View Answer 70. Schizophrenia. He has been handcuffed to the bed by hospital security and is straining at his restraints.. and he is very upset that you wish to measure his vital signs with the equipment in the room. the young man appears agitated. Add gabapentin View Answer 69.” Upon examination.” The most likely diagnosis at this point is: a.Ovid: Blueprints Psychiatry a. Heroin intoxication c. “You are going to give me away. The nature of the disturbance is unclear. A 27-year-old man complains of excess sleepiness during the day and having intense dreams at times when file:///C|/Documents%20and%20Settings/ASUS/My.

The patient suffered no head injury or loss of consciousness during the accident.Ovid: Blueprints Psychiatry he thinks he is still awake. Administration of zolpidem (Ambien) at bedtime to improve nighttime sleep c. Dementia b. he reports that he sometimes has “drop” attacks characterized by sudden weakness in his whole body. An appropriate treatment intervention is: a. His medications since arriving in the hospital have included only antibiotics and opiate pain relievers. He notes that he sometimes has an irresistible urge to sleep and has fallen asleep on multiple occasions even while driving.. Continuous positive airway pressure at night to improve abnormal breathing during sleep b. Valproic acid to treat seizure activity d. The diagnosis most consistent with agitation and confusion in this patient is: a. The available history indicates that the patient was involved in a motor vehicle accident 72 hours ago in which he sustained a tibial fracture requiring surgical procedures for repair.htm (47 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . He feels refreshed after a daytime nap.0Folder/Blueprints%20Psychiatry/Questions. Upon questioning.. A 57-year-old man with a past medical history of “liver problems” is seen in psychiatric consultation in the hospital intensive care unit because of agitation and confusion. Antisocial personality disorder file:///C|/Documents%20and%20Settings/ASUS/My. Olanzapine to improve daytime alertness View Answer 71. He remains alert during the drop attacks but does fall to the floor. Modafinil to improve daytime alertness e. Psychotic disorder c. Delirium d.

but he often consumes more than twice that amount. Administration of an antidepressant medication d. Evaluation for pulmonary embolism c. Propanolol to treat hypertension and tachycardia P. The laboratory results for the patient in Question 71 include elevations in multiple liver enzymes with moderate anemia. and thrombocytopenia. leukopenia.130 c. A potentially critical treatment or diagnostic intervention at this point would include: a. Transfusion of packed red blood cells b. Administration of intravenous thiamine e.. Akathisia View Answer 72. Additional history obtained from the above patient's family indicates that he drinks alcohol on a daily basis.0Folder/Blueprints%20Psychiatry/Questions. Intravenous hydration to treat tachycardia file:///C|/Documents%20and%20Settings/ASUS/My. An additional critical treatment at this point would include: a. Buspirone to treat withdrawal symptoms b.Ovid: Blueprints Psychiatry e.htm (48 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . His minimum daily consumption of alcohol consists of a 12-pack of regular beer.. The patient's vital signs reveal a heart rate of 130 beats per minute and a blood pressure of 180/110 mm Hg. Increase in the dosage of opiate pain reliever View Answer 73.

An antihypertensive medication d. Her foster mother says that she can be quite verbally articulate and writes extremely well. The patient in Question 73 responds to treatment. She is awkward in her interactions. Naltrexone View Answer 75.htm (49 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . she tells you about the intricacies of building a radio from scratch. and she often gets lost in the details of projects that she is assigned. A benzodiazepine medication c. Once you ask her about one of her projects. She has trouble seeing the “big picture” of problems that face her. Her foster mother says that the girl has been having difficulties socially in school. An opiate analgesic medication e. An appropriate pharmacological intervention might include: a.Ovid: Blueprints Psychiatry d.. A benzodiazepine to treat withdrawal symptoms e. He is successfully tapered from benzodiazepines and has not required opiate pain relievers for the past 7 days. and she does not make eye contact with you as you enter the room. He expresses a desire to stop drinking alcohol and requests treatment for alcohol dependence. Clonidine to treat hypertension View Answer 74.. An antidepressant medication of the selective serotonin-reuptake inhibitor class b. A 12-year-old girl presents with her foster mother for a routine pediatric visit. You query her for depressive or psychotic symptoms and she denies either. file:///C|/Documents%20and%20Settings/ASUS/My. She has trouble making friends and often has conflicts with classmates. and his confusion and autonomic instability resolve.0Folder/Blueprints%20Psychiatry/Questions. The girl seems quiet.

She blames herself for the failure of her marriage and feels horribly guilty about how the failure of her marriage is affecting her children. Autism c. She tells you that since her divorce 4 months ago. She states that she has never seen a psychiatrist before. she does not even get out of her pajamas. Asperger's syndrome b.. Her friends are concerned because she has not been joining them for their weekly “girls' night out. Increased latency to REM b. She denies any significant anxiety. Increased delta sleep file:///C|/Documents%20and%20Settings/ASUS/My.Ovid: Blueprints Psychiatry She engages with you briefly but still appears uncomfortable. A 40-year-old woman presents to your office for the first time. She also complains of difficulty falling asleep and says that she hasn't felt rested in months. Anxiety disorder not otherwise specified e. The most likely diagnosis is: a.htm (50 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Sleep studies have revealed that which of the following sleep disturbances occur in depression: a. she has been crying all the time. Posttraumatic stress disorder View Answer 76. She reports she has lost about 15 pounds because she has no appetite.” She says she just has no desire to do anything that she used to enjoy. Avoidant personality disorder d. You diagnose the patient as being in the midst of a major depressive episode. She says she has felt so down that she has rarely left her house and on some days.. but her friends encouraged her to make the appointment because they are worried about her.0Folder/Blueprints%20Psychiatry/Questions.

Ovid: Blueprints Psychiatry c.htm (51 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . You realize that this woman has had four episodes in the last 12 months that met the criteria for either a major depressive episode or a manic episode. In November. With seasonal pattern e. With atypical features c.0Folder/Blueprints%20Psychiatry/Questions. With catatonic features b.. You recommend a mood stabilizer that is more effective for the file:///C|/Documents%20and%20Settings/ASUS/My. you recommend changing the patient's treatment. She was doing well in January but then slid into another major depressive episode in February that you were able to treat with medication as an outpatient. you see that you hospitalized her for a major depressive episode 1 year ago in August. In reviewing your notes regarding her clinical course over the last year.. With rapid cycling View Answer 78. With postpartum onset d. her husband called your office because she was demonstrating symptoms of mania again. Just last month in April. Decreased stage 2 sleep d. After refining your diagnosis to bipolar I disorder with rapid cycling in the patient in Question 77. Decreased stage 4 sleep e. Decreased time spent in REM View Answer 77. she had an acute manic episode requiring another hospitalization. What would be the correct specifier to apply to her diagnosis of bipolar I disorder? a. You have been treating a 56-year-old woman for bipolar disorder for the last 15 years.

As a result of these thoughts.htm (52 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Which of the following neurotransmitters has been implicated as a mediator of obsessive thinking and compulsive behaviors? a. she now spends less than 2 hours per day engaged in these repetitive checking behaviors. she used to spend approximately 6 hours a day checking to make sure the P.. Also.0Folder/Blueprints%20Psychiatry/Questions. and bathroom fan are turned off. A 51-year-old woman with a long-standing diagnosis of obsessive-compulsive disorder describes her symptoms to you. She reports recurrent intrusive thoughts that her apartment is going to be destroyed by fire or water damage.Ovid: Blueprints Psychiatry rapid-cycling variant of bipolar disorder. She also checked under both the bathroom and kitchen sinks to make sure that there was no water leak. Lithium b.. iron. Valproate c. Carbamazepine e. Gabapentin View Answer 79.131 stove. You explain to the patient that you will monitor levels of this medication regularly. you explain that you need to check her liver function prior to starting the medication and frequently during the first 6 months. Lamotrigine d. The medication is most likely to be: a. Dopamine file:///C|/Documents%20and%20Settings/ASUS/My. She reports that since beginning treatment with fluvoxamine approximately 5 years ago.

. She would also repeatedly and excessively clean the family home so that “one could eat off the floor. lists.0Folder/Blueprints%20Psychiatry/Questions.” She says that her mother is “extremely stubborn” and always insists that things be done “her way.Ovid: Blueprints Psychiatry b.htm (53 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ .. Obsessive compulsive disorder file:///C|/Documents%20and%20Settings/ASUS/My.” The daughter states that her mother becomes very frustrated when others do not meet her moral and ethical standards. “I have been a perfectionist all my life. “She just can't let it go. Narcissistic personality disorder c. this patient's most likely diagnosis is: a. The daughter says her mother always needed every detail of a project to be perfect. Antisocial personality disorder b. Recently. and schedules. she would spend an inordinate amount of time looking for the list rather than just rewriting it. The daughter reports that her mother has always paid painstaking attention to rules. she would always make detailed “to do” lists.” For example. Her daughter says. For example. Norepinephrine c. This is your first meeting and you ask the daughter to describe her mother's personality.” Based on the information provided. Serotonin e. Her daughter states that if her mother misplaced the list. A 71-year-old woman comes to your office accompanied by her adult daughter. there is one and only one way to load the dishwasher. her mother was very angry because a teenager from the neighborhood kept cutting through her daughter's backyard rather than using the sidewalk. The mother nods her head and concurs saying. She would spend weeks packing in preparation for family vacations. Glutamate d. GABA View Answer 80.

date. the patient bolts from the office and escapes.htm (54 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . The consultant explains in detail the reason the catheter is indicated and the medical consequences of failing to receive appropriate treatment. the patient becomes agitated and refuses the catheter.. Consent b. Obsessive compulsive personality disorder View Answer 81. the patient is alert and oriented to person. “I don't want a catheter. Before you can react. The patient states. An 87-year-old woman with a history of mild mixed dementia is admitted for confusion and a urinary tract infection.Ovid: Blueprints Psychiatry d. Information c.” Which element of informed consent has this patient partially satisfied? a. Concrete logic d. Duty e. The patient calls the landlord by name and mentions that he lives just down the street from her.. Schizoid personality disorder e.0Folder/Blueprints%20Psychiatry/Questions. place. The medical team requests that the psychiatric consultant assess the patient's ability to consent to medical procedures. Capacity View Answer 82. You tell the patient that you are quite concerned about these homicidal feelings and recommend inpatient psychiatric admission. and time. You realize that you file:///C|/Documents%20and%20Settings/ASUS/My. When the nurse attempts to place a Foley catheter to improve urine drainage. On examination. You are working in an outpatient psychotherapy clinic when your patient tells you that she plans to kill her landlord.

diaphoretic. An electrocardiogram reveals sinus tachycardia with ST-segment depressions in the anterior leads.. His vital signs indicate a heart rate of 132 beats per minute with a blood pressure of 175/100 mm Hg. The patient is afebrile. He does not recall a prior diagnosis of hypertension.5 packs of cigarettes per day. On examination. The Tarasoff decision b. The patient complains of chest pain. The M'Naghten rule c. Connecticut d. Abdominal ultrasound b. Liver function tests file:///C|/Documents%20and%20Settings/ASUS/My.Ovid: Blueprints Psychiatry must attempt to warn the patient's landlord about the patient's statements. Negligence View Answer 83. The patient smokes 1.0Folder/Blueprints%20Psychiatry/Questions. Griswold v. or diabetes. and pacing. Your actions are grounded in which of the following legal precedents? a. A 29-year-old man is dropped off by friends at the emergency department. A critical diagnostic test at this point is: a. He has no known prior history of “heart trouble” and denies alcohol or drug use. he is nervous. Hematocrit e.htm (55 of 66) [30/01/2009 06:23:28 ‫]ﻡ‬ . Urine drug screen d. Electroencephalogram c.. hypercholesterolemia. Swedish Common Law e.

The thalamus and cingulate gyrus file:///C|/Documents%20and%20Settings/ASUS/My. Cocaine dependence d.132 pain with cocaine-positive urine tests over the last year. At this point. fornix. Malingering View Answer 85. however. Upon confrontation. Polydrug abuse b. Upon checking the patient's chart from prior visits. A urine test obtained on the patient in Question 83 reveals cocaine and cocaine metabolites in the urine specimen. Myocardial infarction e.htm (56 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ . Antisocial personality disorder c.. The brain stem and frontal lobes b. and mammillary bodies c..0Folder/Blueprints%20Psychiatry/Questions. A 57-year-old man with a history of chronic alcoholism is placed in a nursing home for alcohol-related amnestic disorder. he states that he rarely uses cocaine. The patient has a mild myocardial infarction without significant arrhythmia or other complications. and this was the first time in many months. The hippocampus. you can make the following diagnosis with confidence: a. it is clear that the patient has had several emergency ward visits for chest P.Ovid: Blueprints Psychiatry View Answer 84. This condition is associated with damage to the following brain regions: a.

She avoids socializing and shopping because she fears the episodes will recur. The father says the child is developing well.htm (57 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ . The father said that the boy is sometimes a “sore loser. The caudate and putamen e. The father said that he praises the boy whether he scores or not and tries to teach him new techniques for improving his game when they play together on the weekends. and a fear of losing control. chest pain.Ovid: Blueprints Psychiatry d. with palpitations. The son tells you that he feels like he is a good player and only sometimes thinks that he is the worst player on the team. He sometimes thinks he is “useless” if he doesn't score at a game. Glycine b.. Alterations in the following neurotransmitter system are strongly linked to this disorder: a. Melatonin c. the boy is dealing with what developmental conflict? file:///C|/Documents%20and%20Settings/ASUS/My.0Folder/Blueprints%20Psychiatry/Questions.. He began playing soccer 2 years ago. The cerebellum View Answer 86. Substance P d. GABA View Answer 87. unexpected anxiety. Enkephalin e. diaphoresis. A 25-year-old female has episodes of recurrent. An 11-year-old boy presents in your outpatient clinic with his father for a routine visit. According to Erikson's life cycle stages.” and other times he is pleased with the scores that he achieves.

Intimacy versus isolation b. You examine her and find no evidence that it is abnormal. None has been willing to operate on her nose to fix it.htm (58 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ . The patient has: a.. She pulls out a mirror and looks at herself.0Folder/Blueprints%20Psychiatry/Questions. Exhibitionism c. Borderline personality disorder d. Industry versus inferiority e. “don't you see how ugly it is?” She tells you that she cannot continue walking around in public with this nose.” she says pointing to her nose. A 24-year-old woman presents in the emergency department complaining that her nose is crooked.. He states that he is doing fine and that he has no file:///C|/Documents%20and%20Settings/ASUS/My. Body dysmorphic disorder b. You ask a colleague to examine the patient. A 50-year-old man is brought to your office by his family. Initiative versus guilt d. Posttraumatic stress disorder View Answer 89. and she draws the same conclusion as you. She feels that everyone notices it and has gone to a number of plastic surgeons to try to get it corrected. Ego integrity versus despair View Answer 88. “See. Social phobia e. Identity versus role confusion c.Ovid: Blueprints Psychiatry a.

A head CT scan with and without contrast demonstrated frontal and temporal atrophy. Pick's disease c.0Folder/Blueprints%20Psychiatry/Questions. inconsiderate. A 46-year-old woman presents to you for an initial psychiatric evaluation.. Huntington's chorea d. however. her relationships with her parents. She tells you that she was in psychotherapy for 5 years with a doctor from another city. He has documented mild memory difficulty. A workup to date has included thiamine. The patient was likely undergoing what kind of treatment? a. all of which were normal. and neglects his personal care. folate. Psychoanalytic psychotherapy file:///C|/Documents%20and%20Settings/ASUS/My. states that the patient has become apathetic. but her mood has remained a problem. Alzheimer's disease b.Ovid: Blueprints Psychiatry memory trouble. She met with him several times a week and describes talking with him about her early childhood. The family. vitamin B12. An HIV test was negative. In the end. What is your diagnosis? a. she felt that she understood herself a lot better and could have better relationships..htm (59 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ . and subsequent relationships with important people in her life. Cognitive-behavioral therapy b. He has no history of coronary artery disease or hypertension. Vascular dementia e. She has had long-standing problems with mood and significant difficulties with interpersonal relationships. Creutzfeldt-Jakob disease View Answer 90. niacin levels.

but he did drink a large amount of alcohol one time since he has been on it and did not feel ill.0Folder/Blueprints%20Psychiatry/Questions. Dialectical behavioral therapy View Answer 91. Interpersonal therapy d. he is prescribed a medication that his P.133 doctor at home said would decrease his cravings for alcohol. Behavior therapy e. Naltrexone e. folate.. A 45-year-old alcoholic man with hepatic cirrhosis is admitted for alcohol detoxification. and file:///C|/Documents%20and%20Settings/ASUS/My. Metoclopramide View Answer 92. Buspirone d. He thinks the medicine may have worked because he lost interest in continuing drinking the next day and has not relapsed since. The medication is most likely to be: a. Disulfiram b. The attending physician on call instructs you to treat the patient with routine treatment including thiamine.. A 57-year-old man from out of town sees you in the walk-in clinic to obtain replacement prescriptions because his original prescriptions have been lost.Ovid: Blueprints Psychiatry c. Zolpidem c. He can't recall the name of the medication.htm (60 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ . In addition to paroxetine. He explains to you that he is a recovering alcoholic with depression and anxiety.

Chlordiazepoxide d. hypercholesterolemia. you remember that dementia is a risk factor for the future development of delirium. Clonazepam View Answer 93.0Folder/Blueprints%20Psychiatry/Questions. type 2 diabetes mellitus. She tells you that.htm (61 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ . A reasonable choice is: a. Creutzfeldt-Jacob-related dementia d. hypertension. In reviewing this patient's history. Huntington's-related dementia b..Ovid: Blueprints Psychiatry benzodiazepines. This patient has known risk factors primarily for what type of dementia? a. In thinking about delirium. Parkinson's-related dementia e. HIV-related dementia file:///C|/Documents%20and%20Settings/ASUS/My. Oxazepam b. you learn that he has a 40-pack-year history of cigarette smoking. Buspirone e. and coronary artery disease.. Diazepam c. because the patient likely has impaired hepatic metabolism. Vascular-related dementia c. A 73-year-old man is admitted to the hospital for lobar pneumonia and develops delirium. you should choose a benzodiazepine that is metabolized by conjugation and that doesn't have long-acting metabolites.

but he is still tired. Excitement b.. Hypothyroidism file:///C|/Documents%20and%20Settings/ASUS/My. Resolution d. Desire c. and has fairly frequent headaches.Ovid: Blueprints Psychiatry View Answer 94. A 56-year-old man with a history of mild hypertension and obesity presents to his primary care physician for treatment of daytime sleepiness and fatigue. dozes off quite frequently during the day. After completing the interview. He has been increasing his caffeine intake to the point that he feels jittery and nervous.” After learning a bit about the patient.0Folder/Blueprints%20Psychiatry/Questions. This patient has a disturbance in what phase of the sexual response cycle? a. Orgasm e.htm (62 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ . He states that he sleeps alone after his last bed partner complained that he snored very loudly and sounded like he was choking all night. Plateau View Answer 95.. The patient states that he thinks his sex drive is much lower than that of his peers. you ask him to tell you what he needs help with. you make the following provisional diagnosis for the patient's complaints: a. you ask the patient about his time in bed at night. A 23-year-old man seeks psychological counseling because he is worried that he isn't “normal. He reports that he rarely has a sexual fantasy and almost never has an interest in sex. The patient reports that he has been becoming progressively more fatigued over the past 2 to 3 years and has gained around 25 pounds because he has no energy to move around. After obtaining a detailed medical and psychiatric history.

Hypochondriasis d. some conditions are generally self-limited. As an emergency department triage officer. It is a weak agonist at the µ-opiate receptor and has a half-life of 15 hours.licensed clinics. Marijuana d.htm (63 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ .0Folder/Blueprints%20Psychiatry/Questions. Because of its long half-life. A patient in withdrawal from which of the following medications would most likely necessitate admission? a. Major depression e. you have been asked to develop a protocol for admissions.. Sleep-related breathing disorder f. The drug is administered in government..Ovid: Blueprints Psychiatry b. Hyperthyroidism c. The goal is to alleviate drug hunger and minimize file:///C|/Documents%20and%20Settings/ASUS/My. Barbiturates e. Nicotine View Answer 97. Whereas it is understood that any patient might necessitate admission. the following drug is commonly used as a maintenance medication for individuals with opioid dependence. Narcolepsy View Answer 96. Crystal methamphetamine c. Crack cocaine b.

The patient reports that he's been injecting himself with P.. You tell him that one option is Suboxone. They staged an intervention that led to his referral here. Heroin b. Methadone d. Methadone c. A 35-year-old anesthesiologist is referred to you. He is interested in learning about his treatment options. Naloxone file:///C|/Documents%20and%20Settings/ASUS/My. What medication is found in Suboxone that would account for this phenomenon? a.Ovid: Blueprints Psychiatry drug-seeking behavior. Morphine c.0Folder/Blueprints%20Psychiatry/Questions. for treatment of opioid dependence. You caution the patient that if he were to crush the Suboxone and inject it intravenously.. an addiction psychiatrist. Buprenorphine b. You explain that Suboxone is a pill that dissolves sublingually. Colleagues at the hospital where he works began to notice changes in his behavior and occupational performance. an FDA-approved outpatient treatment for opioid dependence. Hydromorphone View Answer 98. Hydrocodone e. He has tried to quit on his own several times but finds the withdrawal symptoms to be unbearable. The drug described is: a. he would find himself in significant opioid withdrawal.134 gradually increasing doses of fentanyl for the past year.htm (64 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ .

An elderly man is referred to you by his internist because of symptoms of depression. Pedophilia e. A 28-year-old female arrives at your office on time for her weekly psychotherapy session. The patient reports that he indeed had seen a psychiatrist for several sessions about 30 years ago for a “swallowing problem. She appears more distressed than usual.Ovid: Blueprints Psychiatry d. Acamprosate View Answer 99. all the tests file:///C|/Documents%20and%20Settings/ASUS/My. and throat surgeon.. and you ask her if everything is all right.htm (65 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ .. nose. Before she could say anything. Exhibitionism b. She reports that since the subway car was crowded. she appears embarrassed. she suddenly felt a man rubbing his genitals against her back. and the man was gone. Voyeurism View Answer 100. She wasn't able to get a look at him. This man likely suffered from a paraphilia called: a. As you are taking a thorough history. Fortunately. the doors opened.0Folder/Blueprints%20Psychiatry/Questions. Frotteurism d. At first. but then she confides in you that a disturbing incident occurred on the subway on the way to your office. Fetishism c. A few seconds before the doors opened. she had to stand. The surgeon told the patient that he might need a radical surgery. Flumazenil e.” You ask for more details. you ask the patient if he has ever seen a psychiatrist before. and the patient explains that he had felt a knot near his throat and had gone to see an ear.

.Ovid: Blueprints Psychiatry came back negative. the patient reports he began having difficulty swallowing.htm (66 of 66) [30/01/2009 06:23:29 ‫]ﻡ‬ . and the surgery was not recommended. His primary care physician could not find a medical reason for his difficulty swallowing and referred the patient to a psychiatrist for this problem.. however. The most likely diagnosis was: a. Somatization disorder b. Body dysmorphic disorder e. Factitious disorder View Answer file:///C|/Documents%20and%20Settings/ASUS/My.0Folder/Blueprints%20Psychiatry/Questions. Hypochondriasis d. Conversion disorder c. After that. and it was so bad that he couldn't swallow solid food.

73-74:1-15. Title: Blueprints Psychiatry. Review. Maki P. Practice guideline for the treatment of patients with bipolar disorder (revision).349:1738-1749. Jones PB. N Engl J Med. Clinical results for patients with major depressive disorder in the Texas file:///C|/Documents%20and%20Settings/ASUS/My%. Am J Psychiatry.. 2004.58:347-354. Rush AJ. Weinberger DR. dopamine and cortical signal-to-noise ratio in schizophrenia. controlled acute phase trial. Review. Schizophrenia. et al. 2005. Trivedi MH. Marangell LB. Trends Neurosci. Br Med Bull. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Back of Book > References References Chapter 1 Freedman R. Biol Psychiatry. Ronald L. Predictors of schizophrenia review. Winterer G. Sackeim HA. Cowan. Chapter 2 American Psychiatric Association. Veijola J.0Folder/Blueprints%20Psychiatry/References. 2003.. 2005. Rush AJ.27:683-690. Vagus nerve stimulation for treatment-resistant depression: a randomized. Michael J. 2002.Ovid: Blueprints Psychiatry Authors: Murphy. LM Crismon. et al.htm (1 of 12) [30/01/2009 06:23:32 ‫]ﻡ‬ . et al.159(4 suppl):1-50. Genes..

2005. Leckman JF. Ursano RJ. 2005. et al. Arch Gen Psychiatry.73:941-949.0Folder/Blueprints%20Psychiatry/References. et al. Kripke C..htm (2 of 12) [30/01/2009 06:23:32 ‫]ﻡ‬ . Noack P. 2006. Neurobiology of anxiety disorders and implications for treatment. Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Chapter 3 Battaglia M. Am J Psychiatry. Anxiety and panic: from human studies to animal research and back. Youngstrom EA. A metaanalytic review of the efficacy of drug treatment in generalized anxiety disorder. Eth S. A multidimensional model of obsessive-compulsive disorder. Youngstrom JK.161(11 suppl):3-31. Is pharmacotherapy useful in social phobia? Am Fam Physician. Mt Sinai J Med. Mitte K.29:169-179. and Work Group on ASD and PTSD. Mataix-Cols D. J Clin Child Adolesc Psychol. Steering Committee on Practice Guidelines. Neurosci Biobehav Rev. Charney DS..25:141-150. 2004. Garakani A.. 2005. file:///C|/Documents%20and%20Settings/ASUS/My%. et al. Toward an evidence-based assessment of pediatric bipolar disorder.162:228-238. Rosario-Campos MC. 2004. Findling RL. Ogliari A.Ovid: Blueprints Psychiatry Medication Algorithm Project.71:1700-1701. J Clin Psychopharmacol.61:669-680.34:433-448. 2005. Bell C. Steil R. Mathew SJ. 2005. Am J Psychiatry. Review.

behavioral and personality disorders based on fear and anger traits: II.0Folder/Blueprints%20Psychiatry/References. Livesley WJ.1032:104-116.. Kool S. 2005. New A.349:975-986. 2006. 2005. Toward an integrative model of the spectrum of mood.htm (3 of 12) [30/01/2009 06:23:32 ‫]ﻡ‬ . J Affect Disord. Consensus statement on office-based treatment of opioid file:///C|/Documents%20and%20Settings/ASUS/My%. de Maat S.19:131-155.Ovid: Blueprints Psychiatry Chapter 4 Goodman M. Principles and strategies for treating personality disorder. Farre M. Trumble-Hejduk JG. Fiellin DA. et al. genes.94:89-103. Behavioral and molecular genetic contributions to a dimensional classification of personality disorder. 2005. Efficacy of pharmacotherapy in depressed patients with and without personality disorders: a systematic review and meta-analysis. et al. Akiskal HS. genetics and the psychopharmacological treatment. 2003. Can J Psychiatry. Can J Psychiatry. Trauma. Livesley WJ. Chapter 5 Cami J. 2004.50:442-450. Lara DR.50:435-441. Kleber H. J Personal Disord. Siever L.88:269-278. Schoevers R. Review. Implications for neurobiology. N Engl J Med. Annals NY Acad. J Affect Disord. 2005. Paris J. and the neurobiology of personality disorders. Recent advances in the treatment of borderline personality disorder.. Drug addiction. Sci.

Treatment of cocaine dependence and depression. relapse. Chapter 7 file:///C|/Documents%20and%20Settings/ASUS/My%. 2002. Lancet. Chapter 6 Fairburn CG.56:803-809. Biol Psychiatry. Freeman R. 2004.27:153-159. et al. Neurobiology of anorexia nervosa: clinical implications of alterations of the function of serotonin and other neuronal systems.0Folder/Blueprints%20Psychiatry/References. Frank GK. Morrell W. Alcohol and public health. Strober M. discussion S20-21. and Royal College of Physicians. Touquet R. and outcome predictors over 10-15 years in a prospective study. 2003. Babor T. Bulimia nervosa. Rehm J.365: 519-530. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and emergency department. Int J Eat Disord. Evidenced-based treatment of anorexia nervosa. Lilly RZ. Int J Eat Disord 1997. J Subst Abuse Treat. Int J Eating Disorder.. Thomson AD. Rounsaville BJ. 2004. Kaye WH.Ovid: Blueprints Psychiatry dependence using buprenorphine.327:380-381.htm (4 of 12) [30/01/2009 06:23:32 ‫]ﻡ‬ . 2005. Henry SE. Cook CC. Review.37(suppl): S15-19. Bailer UF. 2005.37 (suppl):S26-S30. Br Med J. Alcohol Alcoholism. 2005.37: 513-521. The long-term course of severe anorexia nervosa in adolescents: survival analysis of recovery.. Room R. London.22: 339-360..

Evidence-based treatments in child and adolescent psychiatry: an inventory.115 Khouzam HR. Curr Opin Crit Care.. J Am Acad Child Adolesc Psychiatry. 2003. Asperger's disorder: a review of its diagnosis and treatment. McClellan JM. Werry JS. Zoghbi HY.Ovid: Blueprints Psychiatry Bridge Denckla M.86:173-185. Pietrzik C. P. 2004. Neuroscientist. Schuurmans MJ. Pandharipande P. Int J Exp Pathol. Pirwani N.351:56-67.45:184-191. Int J Geriatr Psychiatry..20:609-615. Brain Dev. ADHD: topic update. 2005. Delirium: acute cognitive dysfunction in the critically ill. N Engl J Med.42:1388-1400. Ely EW. 2005. Clinical subtypes of delirium and their relevance for daily clinical practice: a systematic review.htm (5 of 12) [30/01/2009 06:23:32 ‫]ﻡ‬ . et al. van der Mast RC. Jackson J. Compr Psychiatry.25:383-389. Concepts for the treatment of Alzheimer's disease: molecular mechanisms and clinical application. El-Gabalawi F.11:360-368. Rett's syndrome: a prototypical neurodevelopmental disorder. Neul JL. 2005. Alzheimer's disease.0Folder/Blueprints%20Psychiatry/References. et al. 2004. 2003. 2004. Chapter 8 Cummings JL.10:118-128. Behl C. file:///C|/Documents%20and%20Settings/ASUS/My%. de Rooij SE.

Ovid: Blueprints Psychiatry Chapter 9 Buscemi N.330:891-894.16.htm (6 of 12) [30/01/2009 06:23:33 ‫]ﻡ‬ .49:592-600. 2005. Nat Rev Drug Discov.4:165-171.. Wong ML.0Folder/Blueprints%20Psychiatry/References. et al. Piper A. Evid Rep Technol Assess (Summ). Part I. Bereavement care interventions: a systematic review. Vandermeer B. Suicide and deliberate self harm in young people. antidepressants and suicidality: a critical appraisal. Deliberate self harm (and attempted suicide).125:1-10.49: 652. James A. 2005.13:1200-1211. Review. 2005. Br Med J. Hill M. Friesen C. Pazder R. Manifestations and management of chronic insomnia in adults.3:3. 2004. The persistence of folly: a critical examination of dissociative identity disorder. Can J Psychiatry. Somatization disorder: a practical review. Merskey H. Chapter 11 file:///C|/Documents%20and%20Settings/ASUS/My%.662. Review. The excesses of an improbable concept.. BMC Palliat Care. Licinio J. Chapter 10 Forte AL. 2004. Clin Evid. 2005. Depression. Can J Psychiatry. Soomro GM. et al. 2004. Mai F. Hawton K.

Golden RN.htm (7 of 12) [30/01/2009 06:23:33 ‫]ﻡ‬ . Am J Psychiatry. Review. N Engl J Med. McEvoy JP. 2007. Stroup TS.164:3.58:364-373. et al. Lieberman JA. et al.27(suppl A):S16-24. Effectiveness of olzapine. Vagal nerve stimulation: a review of its applications and potential mechanisms that mediate its clinical effects. The efficacy of light therapy in the treatment of mood disorders: a review and meta-analysis of the evidence. Groves DA.162:656-662. Williams R. et al. 2005.. Stroup S. Wagner KD. Atypical antipsychotics in psychiatric practice: practical implications for clinical monitoring. Gaynes BN. Marangell LB. Ekstrom RD. 2005. Biol Psychiatry.. quetiapine. et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. McEvoy JP. 353:1209-1223. Neurosci Biobehav Rev. et al. Poulin MJ.Ovid: Blueprints Psychiatry Laruelle M.29:493-500. Clin Ther. Chapter 12 George MS. 2005. Lieberman JA. Cortese L. Brown VJ. Can J Psychiatry. Am J Psychiatry. Rush AJ. et al and Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Prog Neuropsychopharmacol file:///C|/Documents%20and%20Settings/ASUS/My%. 50:555-562. Pharmacotherapy for major depression in children and adolescents. Review. 2005. A one-year comparison of vagus nerve stimulation with treatment as usual for treatment-resistant depression.0Folder/Blueprints%20Psychiatry/References. 2005. Narendran R. Frankle WG. and risperiodone in patients with chronic schizophrenia after discounting perphenazine: a CATIE study. 2005. Mechanism of action of antipsychotic drugs: from dopamine D(2) receptor antagonism to glutamate NMDA facilitation.

placebocontrolled.. Review. Chapter 13 Cipriani A. Oakley-Browne M. Review. and role in anxiety. Am J Psychiatry. O'Brien CP. A review of the evidence for carbamazepine and oxcarbazepine in the treatment of bipolar disorder. double-blind. Yatham LN.65(suppl 10):28-35. Clin Evid. Rickels K. 2004. Review. 2006. Chapter 14 Gale C. 2005. J Clin Psychiatry. Review. file:///C|/Documents%20and%20Settings/ASUS/My%. Feiger AD. et al. Rynn MA. Lithium in the prevention of suicidal behavior and all-cause mortality in patients with mood disorders: a systematic review of randomized trials. 1437-1459.Ovid: Blueprints Psychiatry Biol Psychiatry. Int J Neuropsychopharmacol. Generalised anxiety disorder.htm (8 of 12) [30/01/2009 06:23:33 ‫]ﻡ‬ . and dependence.7:507-522.66(suppl 2):28-33. 2004.29:819-826. Benzodiazepine use.67:1354-1361. Roy-Byrne PP. et al. Kasper S. 2004. J Clin Psychiatry. J Clin Psychiatry. Hirschfeld RM..162:1805-1819. flexible-dose titration trial.0Folder/Blueprints%20Psychiatry/References. Review. The GABA-benzodiazepine receptor complex: structure. Review. function.66(suppl 2):14-20. Selegiline transdermal system for the treatment of major depressive disorder: an 8-week. J Clin Psychiatry. 2005. Hawton K. abuse. Newer anticonvulsants in the treatment of bipolar disorder. 2005. 2005. Pretty H.

2004. Psychiatr Clin North Am. Review. Refining treatment guidelines in Alzheimer's disease. Neurol Clin.(suppl):14-20. Br Med J. Review. Kaduszkiewicz H.28:255-274. Chapter 17 file:///C|/Documents%20and%20Settings/ASUS/My%..22:389-411.116 Sachdev PS.0Folder/Blueprints%20Psychiatry/References. Geriatrics. N Engl J Med.27:695-714.331: 321-327.. 2005.htm (9 of 12) [30/01/2009 06:23:33 ‫]ﻡ‬ . Recent advances in the treatment of opiate addiction.6:339-346. Beck-Bornholdt HP.Ovid: Blueprints Psychiatry Chapter 15 Boothby LA. Chapter 16 Bhanushali MJ. Clin Ther. The evaluation and management of patients with neuroleptic malignant syndrome. Review. Review. Neuroleptic-induced movement disorders: an overview. P. Cholinesterase inhibitors for patients with Alzheimer's disease: systematic review of randomised clinical trials. Review. 2005. 2004. 2005. Zimmermann T. Doody RS. 2005.352:1112-1120. 2005. Curr Psychiatry Rep. et al. Acamprosate for the treatment of alcohol dependence. Review. Woody GW. Shannon M. Doering PL. Tuite PJ. The serotonin syndrome. Boyer EW. Fudala PJ.

Review. Leichsenring F.18:73-89. 2004. and future directions. Review. de Jesus Mari J.32:263-273. Robins CJ. NeuroRx. J Personal Disord. Dialectical behavior therapy: current status. 2006.61:1208-16. Leibing E.255:75-82. Kim SY. recent developments.Folder/Blueprints%20Psychiatry/References. Clin Psychol Rev. 4th ed. 2006.Ovid: Blueprints Psychiatry de Mello MF. Court responses to Tarasoff statutes. J Am Acad Psychiatry Law. Bacaltchuk J. 2004. Chapman AL. Enduring effects for cognitive behavior therapy in the treatment of depression and anxiety. Chapter 18 Kachigian C.. 2005. A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. Diagnostic and Statistical Manual of Mental Disorders. 2004. Karel MJ. Eur Arch Psychiatry Clin Neurosci. Empirical advances in the assessment of the capacity to consent to medical treatment: clinical implications and research needs. Strunk D. et al. Hollon SD. Rabung S. General American Psychiatric Association.. -Text file:///C|/Documents%20and%20Settings/ASUS/My.1:372-377. et al. Evidence-based ethics for neurology and psychiatry research. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a metaanalysis. Stewart MO. Moye J. 2004.26: 1054-1077. Arch Gen Psychiatry. Annu Rev Psychol.htm (10 of 12) [30/01/2009 06:23:33 ‫]ﻡ‬ .57:285-315. Gurrera RJ. Felthous AR.

Philadelphia. Washington. 2005. Rosenbaum JF. Abnormal Psychology. Wedding D. Yudofsky SC. New York. DC: American Psychiatric Association. Adams and Victor's Principles of Neurology. Cambridge. 6th ed.. 1985. 59th ed. 2003. Ropper AH. Black DW. PA: Lippincott file:///C|/Documents%20and%20Settings/ASUS/My. 2003. MA: Harvard University Press. 2000. DC: American Psychiatric Publishing. Handbook of Psychiatric Drug Therapy. Davison GC. Arana GW. Belmont. Brown RH.. CA: Wadsworth. 4th ed. 2006. 4th ed. et al. 2000. Kaplan and Sadock's Synopsis of Psychiatry. NJ: Medical Economics. Montvale. Neale JM. Sadock BJ. 5th ed. Philadelphia. Corsini RJ. Williams & Wilkins. Hales RE. 10th ed. Chemotherapy in Psychiatry: Principles and Practice. Textbook of Clinical Psychiatry. Sadock VA. NY: John Wiley & Sons. Andreason N. Kring AM. Baldessarini RJ. NY: McGraw-Hill Professional. Introductory Textbook of Psychiatry.htm (11 of 12) [30/01/2009 06:23:33 ‫]ﻡ‬ .Ovid: Blueprints Psychiatry Revision. Washington. DC: American Psychiatric Publishing. Physicians' Desk Reference.Folder/Blueprints%20Psychiatry/References. PA: Lippincott. Washington. 2005. New York. 8th ed. Current Psychotherapies. 9th ed. 2005.

. file:///C|/Documents%20and%20Settings/ASUS/My.Folder/Blueprints%20Psychiatry/References..Ovid: Blueprints Psychiatry Williams & Wilkins.htm (12 of 12) [30/01/2009 06:23:33 ‫]ﻡ‬ . 2007.

anxiety.. Signs and symptoms of sedative-hypnotic withdrawal include restlessness. Patients with a more serious dependence or with multiple comorbid medical illnesses. Ronald L.htm (1 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . Benzodiazepine and barbiturate withdrawal can be a life-threatening condition. tremors. can be associated with increased risk of type II diabetes mellitus.%20Folder/Blueprints%20Psychiatry/Answers. 5th Edition Copyright ©2009 Lippincott Williams & Wilkins > Back of Book > Answers Answers 1. It is important to regularly monitor weight. 2. however. Most acute seizures occur within 48 hours of ischemic stroke onset and would likely have been preceded by file:///C|/Documents%20and%20Settings/ASUS/My. vomiting. Cowan. weakness. particularly olanzapine and clozapine. Diabetes insipidus (a) and hypothyroidism (d) are potential side effects from chronic treatment with lithium. Michael J. as well as weight gain and dyslipidemia. Many patients who have mild dependence on benzodiazepines can be managed by a slow taper of the drug in an outpatient setting. the primary diagnostic consideration is sedative-hypnotic withdrawal. c (Chapter 5) At this point.Ovid: Blueprints Psychiatry Authors: Murphy.. Because many of these drugs have long-acting metabolites. c (Chapter 11) Atypical antipsychotics. These drugs are widely used to treat anxiety disorders. and fasting blood glucose in all patients taking atypical antipsychotics to monitor for these severe side effects. the patient may not show signs of withdrawal for 7 to 10 days after stopping all drugs. sweating. hyperreflexia. lipid profile. Leukopenia (e) is a rare but life-threatening adverse effect from treatment with clozapine. and seizures. Title: Blueprints Psychiatry. require a protocol withdrawal in an inpatient setting..

or altered level of consciousness. Grandiose delusions are a false belief that the individual has special abilities or is in other ways much more important than reality indicates. c (Chapter 1) Unfortunately. This kind of nonbizarre delusion is characteristic of delusional disorder if there are no other psychotic symptoms. but there is no evidence from the history to suggest that the patient is alcohol dependent. Antipsychotic medications are appropriate but often ineffective treatment. as well as hyponatremia. grossly disorganized or catatonic behavior..%20Folder/Blueprints%20Psychiatry/Answers. 3. paralysis. Jealous delusions are when a person becomes falsely convinced that his or her lover is unfaithful.Ovid: Blueprints Psychiatry signs of a stroke including dysarthria. and poor self-care are examples of negative symptoms for 2 years or file:///C|/Documents%20and%20Settings/ASUS/My. Acute metabolic disturbances can precipitate seizures in individuals of any age. or negative symptoms. Alcohol withdrawal produces signs and symptoms similar to those of sedative-hypnotic withdrawal. and uremic and hepatic encephalopathy are all causes of acute symptomatic seizures. Somatic delusions involve the false belief that the person has a bodily function disorder. disorganized speech. 4. Persecutory delusions are when a person becomes falsely convinced that others are out to harm him or her and that he or she is being conspired against in general. The delusion must be present for at least 1 month. d (Chapter 1) This would be classified as an erotomanic delusion because the patient's mother was falsely convinced that this man was in love with her. isolation. The primary treatment is supportive psychotherapy. two (or more) of the following criteria must be met: hallucinations. This young man's conversations with people who are not there likely represent hallucinations.htm (2 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . To make the diagnosis of schizophrenia. His lack of motivation. taking care neither to support nor to refute the delusion but to maintain an alliance with the patient.. this young man's diagnosis based on the history given is likely schizophrenia. The normal laboratory studies make these etiologies less likely. however. A medical or substance-related condition must be ruled out. hypocalcemia. delusions. Both hypoglycemia and nonketotic hyperglycemia occurring in poorly controlled diabetes.

Negligence includes failing to meet the standard of care. The patient must be ill for at least 6 months to meet criteria for schizophrenia. Because the patient's symptoms have developed over 2 years.. The first line of treatment for the symptoms is an anticholinergic agent. and Tourette's syndrome. This is in contrast to schizophreniform disorder P. 5. b (Chapter 16) This patient has developed oculogyric crisis. followed by eventual return to premorbid functioning.136 that fails to last for 6 months and does not involve social withdrawal. to treat akathisia (another side effect of psychotropic medications). Brief psychotic disorder lasts no more than 1 month. 6. an acute dystonia of the ocular muscles induced by antipsychotic file:///C|/Documents%20and%20Settings/ASUS/My. Atenolol is a β-blocker and may be used to manage blood pressure. Major depressive disorder can present with psychotic symptoms occurring in the context of a major depressive episode. b (Chapter 15) The patient described is experiencing extrapyramidal symptoms. direct causation.. Of all the agents listed.%20Folder/Blueprints%20Psychiatry/Answers. 7. duty. and other conditions. Clonidine is primarily used as an antihypertensive and is effective in the treatment of opiate withdrawal. this supports a diagnosis of schizophrenia. and damages. The patient's history does not suggest major depression but rather a 2-year period of increasing negative symptoms followed by positivesymptom psychosis. attention-deficit disorder. There must also be social or occupational dysfunction as evidenced by his poor school performance. d (Chapter 18) Malpractice requires the presence of four elements: negligence. Methylphenidate and pemoline are both psychostimulants. only benztropine is primarily an anticholinergic medication.Ovid: Blueprints Psychiatry more.htm (3 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ .

Antipsychotic-induced dystonias may be prevented or treated with anticholinergic medications such as benztropine or diphenhydramine. Delta sleep is a subdivision of NREM sleep comprising stages 3 and 4. Pain disorder is suspected when psychological factors play a major role in mediating expression and impact of pain. a (Chapter 9) Somatization disorder is characterized by multiple chronic medical complaints that include pain. β-adrenergic antagonists are sometimes used to treat autonomic anxiety symptoms in social phobia. particularly high potency antipsychotics such as haloperidol. (3) at least one sexual symptom (not sexual pain). and pseudoneurological symptoms that are not caused by a medical illness. Nightmares generally occur during REM sleep. 9. 8. His risk factors include young age. c (Chapters 7 and 9) The child is likely experiencing sleep terror disorder that occurs during delta sleep.htm (4 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . α-2 adrenergic agonists (a) are used to treat the autonomic symptoms of opioid withdrawal. Stage 0 is awake. sexual symptoms.%20Folder/Blueprints%20Psychiatry/Answers. A particularly feared antipsychotic-induced dystonia is laryngospasm caused by the resulting airway compromise. 3.. male sex and the recent introduction of antipsychotic medication.. Selective serotonin reuptake inhibitors (e) are used in the treatment of major depression and a wide variety of anxiety disorders. gastrointestinal disturbances. (2) two gastrointestinal symptoms. and 4. Cholinesterase inhibitors (d) are cognitive enhancers used in the treatment of Alzheimer's disease and other dementing illnesses. and (4) one pseudoneurological symptom. Conversion disorder involves complaints of sensory or motor dysfunction that are not the result of neurologic dysfunction.Ovid: Blueprints Psychiatry medications. Body dysmorphic disorder is characterized by excessive concern with a perceived defect in appearance. The history of physical complaints must start before age 30. Hypochondriasis is characterized by a preoccupation with having serious disease based on a misinterpretation of bodily function and sensation. 2. Non-rapid eye movement (NREM) sleep includes stages 1. The diagnosis of somatization disorder can be challenging because it requires the presence of (1) four pain symptoms at different sites or in different bodily functions. file:///C|/Documents%20and%20Settings/ASUS/My.

. 11. diaphoresis). (2) Appreciation of the risks. (3) Ability to rationally manipulate information (reason). parotiditis (swollen parotid glands). Vomiting causes a hypokalemic hypochloremic metabolic alkalosis that can result in the feared complication of cardiac arrhythmias. In addition. and sometimes the use of dopamine agonists such as bromocriptine. and Russell's sign secondary to self-induced vomiting as a purging behavior to avoid weight gain from binges. dehydration (dry skin).%20Folder/Blueprints%20Psychiatry/Answers. She shows signs of bulimia nervosa including maintenance of body weight. d (Chapter 6) This patient's cardiac arrest was caused by hypokalemia (d). Her risk factors include rapid antipsychotic dose escalation and dehydration secondary resulting from the breakdown of her air conditioner. Treatment involves immediate discontinuation of the antipsychotic. P. motor abnormalities (rigidity.. and alternatives to the proposed treatment.htm (5 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . This requires the demonstration of four elements: (1) Understanding the nature of one's illness.Ovid: Blueprints Psychiatry 10. dantrolene to treat muscular rigidity. benefits. and behavioral changes (delirium). a potentially life-threatening complication of treatment with antipsychotics. mutism). The laboratory finding of a grossly elevated creatine kinase level is a prominent feature of neuroleptic malignant syndrome. The syndrome includes autonomic instability (hyperthermia. and (4) Ability to communicate a choice. and liver function is typically abnormal. supportive measures.137 12. a (Chapter 16) This patient has developed neuroleptic malignant syndrome. white blood cell count is frequently elevated. a (Chapter 18) This patient's lack of insight into his mental illness results in inability to understand the nature of his illness (a). EKG changes file:///C|/Documents%20and%20Settings/ASUS/My. Capacity is defined as a patient's ability to make a decision (positive or negative) regarding treatment.

14.Ovid: Blueprints Psychiatry caused by hypokalemia include flattening of the T wave and a U wave (positive deflection following a T wave).%20Folder/Blueprints%20Psychiatry/Answers. a (Chapter 17) Cognitive behavioral therapy (CBT) was originally developed as a psychotherapeutic treatment modality for mild-to-moderate depression.htm (6 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . Long-term psychodynamic therapy (e) seeks to improve understanding of one's psyche including unconscious conflicts and defense mechanisms to bring about improved self-realization and change. The technique described cognitive-behavioral therapy. which focuses on improving the patient's interactions with others.. which generally diminishes the panicky response. Classical conditioning is a form of learning in which a neutral stimulus is repetitively paired with a natural stimulus with the result that the previously neutral stimulus alone then becomes capable of eliciting the same response as the natural stimulus. It has also subsequently gained strong empirical validation for the treatment of social phobia. also has significant empirical support in the treatment of depression. Many psychodynamic concepts originate from the work of Sigmund Freud.. d (Chapter 3) The symptoms described are consistent with a panic attack. A late manifestation of hypokalemia is pulseless electrical activity. 13. Dialectical behavior therapy (b) incorporates CBT and Eastern Zen philosophy and is the psychotherapeutic modality of choice for treatment of borderline personality disorder. panic disorder. Subsequently. and there is significant evidence of its efficacy in both treatment and prevention of relapse in this context. Family therapy (d) focuses on interactions between family members to improve functioning of the family unit as a whole and is of particular benefit in child psychiatry. Interpersonal psychotherapy. the patient will learn that the sensations are innocuous and self-limited. obsessive-compulsive disorder. CBT involves identifying and gently challenging distorted core beliefs and the use of behavioral techniques to produce change in mood and behavior. Exposure therapy (c) is used in the treatment of specific phobias. file:///C|/Documents%20and%20Settings/ASUS/My. Exposure therapy involves incrementally confronting a feared stimulus. and posttraumatic stress disorder.

This reduces the enzyme's activity. and serotonin. a (Chapters 12 and 14) Alprazolam is a benzodiazepine and acts at the GABA receptor. Clozapine can cause seizures and may be a contributing factor to the seizure but would not cause hyponatremia. a (Chapter 6) The patient is likely inducing vomiting mechanically with her right index finger. which is to hydrolyze acetylcholine in the synapse. Esophageal rupture is also a possible complication of induced vomiting. dopamine.. d (Chapter 15) Donepezil and tacrine both reversibly bind the enzyme acetylcholinesterase. The syndrome of inappropriate antidiuretic hormone secretion. 17. Phenelzine is a monoamine oxidase inhibitor that blocks the presynaptic enzymes that catabolize norepinephrine. Imipramine is a tricyclic antidepressant and acts by blocking presynaptic reuptake of serotonin and norepinephrine. 16.htm (7 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . these drugs reduce cognitive impairment. file:///C|/Documents%20and%20Settings/ASUS/My.%20Folder/Blueprints%20Psychiatry/Answers. is an unlikely cause of the hyponatremia in a nonsmoker with a normal chest radiograph. 18.Ovid: Blueprints Psychiatry 15. d (Chapter 1) The patient presents with seizure that is most likely a result of acute hyponatremia. This has resulted in hypokalemia. this effect wanes with the progressive loss of cholinergic neurons that is seen in this disease. The hyponatremia could have many causes. Reducing the activity of acetylcholinesterase is thought to raise the presynaptic concentration of acetylcholine released by axons of the remaining cholinergic neurons. which is often associated with oat cell carcinoma of the lung. Paroxetine is a selective serotonin-reuptake inhibitor. Initially. Patients with bulimia nervosa may maintain near-normal body weights. Mirtazapine blocks the α-2 reuptake receptor and also has postsynaptic activity.. which has produced the characteristic electrocardiographic findings and cardiac arrhythmia. however.

c (Chapter 4) This patient shows many of the common features of borderline personality disorder. and self-injurious behavior. This level of mild hypertension would not have neurologic effects. She undoubtedly experiences anxiety related to her maladaptive coping style. perceives that she has been abandoned by the nurse.%20Folder/Blueprints%20Psychiatry/Answers. Serotonin syndrome can cause confusion but does not cause seizures or hyponatremia. d (Chapter 4) This man exhibits some common signs of narcissistic personality disorder.138 rates of depression.. Although she displays some self-centeredness in her perception of the clinical staff interaction. 20. Although patients with this disorder have high P. grandiosity about his capabilities despite several failed jobs.. but she does not provide evidence of a persistent pattern of worrying that would characterize generalized anxiety disorder. The aloofness and grandiosity are off-putting and diminish empathy from others for one's underlying pain. She displays maladaptive coping patterns to routine stress. The diagnosis of exclusion would likely be polydipsia and is suggested by the staff person reporting her excessive cola drinking. she does not meet criteria for an episode currently. emotional lability. as the patient does not experience sexual gratification from the behavior but rather a relief of emotional distress. the self-injurious behavior of cutting or scratching her thighs would not constitute masochism. Humiliation followed by anger is also a common manifestation of narcissistic personality. and his sensitivity to a mild suggestion that he might have a problem are behaviors seen commonly with this disorder. His disregard of the time of the appointment. as a consequence of the difficulties. Finally. The condition can be quite disabling. His interest in file:///C|/Documents%20and%20Settings/ASUS/My. the major issue is that she perceived being abandoned by the nurse.Ovid: Blueprints Psychiatry Hypertension can lead to cerebral dysfunction but not usually seizures. such individuals have tolerated the perceived slights omnipresent in nearly every job setting. 19.htm (8 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ .

He exhibits no features of dependent personality disorder (extreme neediness and reliance on others for emotional support and decision making). What is unclear. He is not self-destructive. The diagnosis is unclear. making borderline personality disorder unlikely. Her clinical history is not consistent with major depression. The violence clearly warrants a hospitalization. 21. or afraid of abandonment. Commonly. but the first thing that should be done is discontinuation of the dextroamphetamine. Further treatment might include either an antipsychotic or a mood stabilizer. not the constant worrying of a person with generalized anxiety. a complication of panic disorder that this patient has developed. d (Chapter 7) The girl exhibits selective mutism. e (Chapters 7 and 15) The child has developed symptoms of mania and psychosis while in the first few months of dextroamphetamine therapy for a presumed case of attention-deficit disorder. Her anxiety comes in classic waves of panic. An antidepressant would be contraindicated in a patient without depression or anxiety who may be having a manic or psychotic episode. b (Chapter 3) This patient has untreated panic disorder with a relatively late onset of the disorder. is whether the symptoms are solely caused by treatment or if the patient is having an initial episode of bipolar disorder or schizophrenia. 23. impulsive.Ovid: Blueprints Psychiatry interacting and pursuing work relationships makes schizoid personality disorder unlikely.. Group therapy would be helpful after the acute stabilization but is not the first step in management. his admission of inadequacy is not consistent with a persistent. children with this condition will speak normally at home but become file:///C|/Documents%20and%20Settings/ASUS/My. 22. especially given the extensive family history. She has neither the specific fear of spiders necessary to diagnose arachnophobia nor the obsessions and compulsions of obsessive-compulsive disorder. She has a family history of agoraphobia.%20Folder/Blueprints%20Psychiatry/Answers.. Although he is grandiose. delusional grandiosity.htm (9 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ .

The patient had successfully detoxified prior to being found unresponsive. piloerection. The initial symptoms of lacrimation.. Children with selective mutism can be treated with a social group and antidepressant medication targeting their social anxiety. but we have no evidence of this currently. 24. You had prescribed an inpatient admission for opiate detoxification followed by outpatient psychotherapy and self-help group involvement. Abulia is a neurological condition that results in a lack of affective expression. She and her family and teachers should be queried about the possibility of a school-related abuse situation leading to posttraumatic stress disorder. After confrontation during the initial visit. Some children will go on to develop social anxiety disorder or depression in later life. Children with autism fail to relate in all contexts. Although this selectively mute child might be depressed. and mild tachycardia are consistent with opiate withdrawal. The laboratory test you ordered was a urine drug screen that was positive for opiate metabolites. dilated pupils. mild fever. the patient confessed that she had sought opiate prescriptions from multiple physicians and had also been stealing narcotics from the hospital by pretending to give them to patients and then pocketing them. flumazenil is a benzodiazepine antagonist.htm (10 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . Naloxone is an opiate antagonist that can be lifesaving in cases of opiate overdose. her activity outside of school suggests otherwise.139 file:///C|/Documents%20and%20Settings/ASUS/My. Acamprosate is useful in the treatment of alcoholism. Physostigmine is helpful in treating anticholinergic toxicity. Thiamine and glucose are important treatments in patients who are found unresponsive and would also be important in the management of this patient in case other factors were contributing to the diagnosis. Clonidine may help with symptoms of opiate withdrawal but not with opiate intoxication. Alprazolam is a benzodiazepine that is useful in alcohol withdrawal.%20Folder/Blueprints%20Psychiatry/Answers.Ovid: Blueprints Psychiatry mute at school. P. It is believed to be a childhood form of social anxiety disorder. not just at school.. e (Chapters 5 and 15) The patient has opiate dependence and is most likely suffering from an opiate overdose. Of the listed treatments.

If his IQ were less than 50 but more than 30. This couple may have alcoholism. but risk management should be called only after social services have consulted on the case. A reporting physician may be sued by the accused abusers. whereas if it were 20 to 30. he would have moderate mental retardation. It falls in the mild range. Therefore.Ovid: Blueprints Psychiatry 25. 26.. children with Asperger's disorder have either a normal or a high IQ and have awkward social skills with poor eye contact. c (Chapter 10) Patients suffering from abuse sometimes appear for treatment with their abusers. Before finalizing this diagnosis.. you may arouse suspicion in the abuser who may then take the abused patient and leave. and the child should be educable but will require a special education curriculum. Finally. given the presence of an alcohol smell on their breath without evidence of intoxication. 27. Finally. Your primary fiduciary responsibility is to your patient. a potential sign of high alcohol tolerance.htm (11 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . Abused people may be afraid to confront their abusers because of fear of retaliation.%20Folder/Blueprints%20Psychiatry/Answers. it would not be appropriate to call the police or to confront the suspected abuser without more information. b (Chapter 7) This child has mental retardation. it is generally better to leave this in the hands of experienced social workers who can sort out the social situation and report the appropriate persons to authorities. the retardation would be severe. Although it may be tempting to confront the suspected perpetrators. He does not appear to have autism because he is able to communicate and makes eye contact. The best file:///C|/Documents%20and%20Settings/ASUS/My. If you try to get more information with the alleged abuser present. it would be important to rule out all potential medical causes for his poor intellectual function. Sending the patient home and arranging for outpatient follow-up leaves the patient at significant risk and violates mandated reporting laws in many states. calling around in an investigative mode violates patient confidentiality and is outside the role of a physician treating a patient. b (Chapter 10) Suspected cases of elder abuse need to be reported to social services.

29. Because lithium has a narrow therapeutic window. This is neuroleptic malignant syndrome until proven otherwise. and gastrointestinal symptoms are not present. and arrhythmias. Tardive dyskinesia is not associated with fever and akinesis. confusion and ataxia..Ovid: Blueprints Psychiatry option is to find a tactful way to speak with the patient alone to ask about potential abuse. Suicide is more common in Caucasians than African Americans (a). being employed (c). A dystonia would be localized to one or two muscle groups and would not cause the systemic signs. The mainstay of treatment for file:///C|/Documents%20and%20Settings/ASUS/My. b (Chapter 11) The patient is rigid. but the characteristic symptoms of shivering. At toxic doses. Serotonin syndrome should be thought of. this patient has reached toxic serum levels as a result of doubling her dose. 28. With this approach. do not risk your intervention resulting in more harm to the patient. coma. Pneumonia would cause the systemic signs but not the focal neurological signs. you preserve your patient's right to privacy. hyperreflexia. and provide a safe opportunity for the patient to seek help from a physician. lithium causes a coarse tremor. akinetic. Muscular rigidity commonly suggests neuroleptic malignant syndrome but can develop in severe cases of serotonin syndrome. 30. hyperpyrexic. d (Chapter 10) Men are more successful at completing suicide than women. Lithium toxicity can be life threatening because of risk of seizures. gastrointestinal problems such as diarrhea. c (Chapter 13) Side effects of lithium at a normal dose include tremor. and unresponsive with an elevated creatine phosphokinase level. and religious faith (e) are protective factors against suicide. and minor cognitive impairment.htm (12 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ .%20Folder/Blueprints%20Psychiatry/Answers. possibly because they are more likely to use methods of higher lethality such as shooting or jumping rather than overdose or drowning.. Living with dependent children (b). clonus.

diarrhea. Alzheimer's disease (a) typically presents after age 65 with insidious onset of short-term memory impairment. Vitamin E deficiency (e) can cause ocular signs followed by long tract signs such as muscle weakness. agranulocytosis. and prominent frontal and temporal atrophy on neuroimaging are all consistent with the diagnosis of Pick's dementia. many patients will progress to develop Korsakoff's psychosis. She is disinhibited. 32. and aplastic anemia. which are typical signs of Korsakoff's psychosis. transaminitis. B12 deficiency (a) causes megaloblastic anemia and peripheral neuropathy caused by demyelination of the dorsal columns and corticospinal tracts. which is caused by alcohol dependence. ataxia. If this is not reversed immediately with intravenous thiamine repletion. Carbamazepine (d) may cause gastrointestinal distress. 31. d (Chapter 5) This patient is exhibiting anterograde amnesia and confabulation. Niacin deficiency (c) results in pellagra with dermatitis. which is irreversible in two thirds of cases. Valproic acid (e) is associated with gastrointestinal distress. This is a consequence of thiamine deficiency. coma.htm (13 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . The thiamine-deficient patient initially develops Wernicke's encephalopathy. and dementia.%20Folder/Blueprints%20Psychiatry/Answers.. coma. and mental confusion. Lamotrigine (b) can cause severe life-threatening rashes including Stevens-Johnson syndrome. and rarely fatal hepatotoxicity.Ovid: Blueprints Psychiatry severe lithium intoxication is hemodialysis. which is a triad of nystagmus.. Haloperidol (a) may be associated with acute extrapyramidal side effects and QTc prolongation on EKG. resulting in an inability to observe typical social mores. The early age of onset of a dementing illness. encompassing the prominent feature of marked P. Folic acid deficiency (b) causes macrocytic anemia. d (Chapter 8) This patient has developed the insidious onset of cognitive decline. family history of early-onset dementia. HIV-related dementia (b) presents as global cognitive decline usually in the late stages of AIDS.140 personality change. Huntington's dementia (c) presents with other typical features of Huntington's disease including early onset (typically during the mid-30s) and choreiform movements with prominent file:///C|/Documents%20and%20Settings/ASUS/My.

There may be focal findings on neurological examination. hypertension. an anticonvulsant mood stabilizer. and exaggerated file:///C|/Documents%20and%20Settings/ASUS/My. 34. d (Chapter 4) This patient exhibits features of histrionic personality disorder. d (Chapter 5) This patient has a history of sedative-hypnotic dependence for alprazolam and is admitted with signs of acute intoxication including altered mental state (agitation) and respiratory depression. would be the most helpful. grandiosity. and neuroimaging typically shows multiple areas of pathology. Fluoxetine would not treat the mania and may. and methadone (c).Ovid: Blueprints Psychiatry caudate atrophy on neuroimaging. After intubation for 1 day. are used in the treatment of opioid dependence. a benzodiazepine antagonist.. would not have any impact. Acamprosate counteracts alcohol dependence but does not improve mania. in fact. does not treat mania and would be less effective than standard treatments such as valproic acid. decreased need for sleep. tachycardia.. 33. Gabapentin.%20Folder/Blueprints%20Psychiatry/Answers. diaphoresis. e (Chapters 2 and 13) The patient shows classic symptoms of mania: rapid speech. although initially suspected of having mood-stabilizing properties. the patient exhibits acute agitation. worsen it. Flumazenil. and spending sprees. Propranolol (e) is a nonselective β-adrenergic antagonist that is sometimes used in the treatment of social phobia. 35. valproic acid. Buprenorphine (a).htm (14 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . a µ-opioid receptor partial agonist. Of the medicines listed. and tremor. Clonidine (b) is an α-2 receptor agonist that treats the autonomic symptoms of opioid withdrawal. inappropriate flirtation. which is managed by detoxification with phenobarbital (a long-acting barbiturate) or a benzodiazepine with a long half-life. These include attention-seeking and theatrical behaviors such as wearing dramatic and seductive clothing and makeup. These signs and symptoms are consistent with acute withdrawal. Vascular dementia (e) typically presents with stepwise cognitive decline in the setting of cardiovascular and cerebrovascular risk factors. a weak µ-opioid receptor agonist.

Ovid: Blueprints Psychiatry emotional responses to events of little significance. Dissociative amnesia (c) involves the temporary inability to recollect important personal information. Dependent personality disorder (c) is associated with extreme dependence on others and fear of separation. Separation anxiety disorder is characterized by anxiety as evidenced by behavioral disturbance (such as crying) when separated from a primary caregiver. 37. Patients with this diagnosis often believe that their relationships are more significant than they actually are. in which circumstance attention-deficit/hyperactivity disorder would be diagnosed. Avoidant personality disorder (b) is associated with avoidance of relationships resulting from feelings of inadequacy. Dementia (b) typically has a more insidious course and features prominent memory impairment in the absence of altered conscious level. Conduct disorder is a behavioral disturbance in which a child violates the basic rights of others and does not adhere to rules and societal norms. Clues include acute onset over the course of days. It may be accompanied by hyperactivity. Patients with schizoid personality disorder (e) are emotionally detached.%20Folder/Blueprints%20Psychiatry/Answers.htm (15 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . 36. impairment in attention. with acute global cognitive dysfunction precipitated by infection. and (3) stereotyped behavior or interests. namely: (1) impaired social interactions. (2) impaired communication. so he would not meet the criteria for schizophrenia. Attention-deficit disorder is characterized by a persistent attention disturbance in at least two different settings (such as school and home). Patients with antisocial personality disorder (a) disregard societal rules and lack a sense of remorse. and impaired memory and orientation. The child does not display evidence of a formal thought disorder or ongoing psychosis. a (Chapter 7) This child displays the classic diagnostic criteria for autism. Major depressive disorder (d) can present with apparent memory impairment termed file:///C|/Documents%20and%20Settings/ASUS/My. waxing and waning of conscious level over the course of the day with particular confusion and agitation at night (“sundowning”). It is the childhood equivalent of antisocial personality disorder in adults.. a (Chapter 8) This patient is exhibiting signs of delirium..

there is no evidence of the magical thinking that would characterize schizotypal personality disorder. He likely fears abandonment by the mother on whom he depends. but he differs from those with borderline personality disorder in that he has a more stable sense of self and is not impulsive and self-destructive. he is not an aloof. including making minor decisions. but patients typically exhibit normal cognitive functioning with encouragement and careful interviewing. Although intermittent psychotic symptoms (particularly hallucinations) may occur in delirium. Although the patient works in an often-solitary job. c (Chapter 11) The patient has moderate granulocytopenia. file:///C|/Documents%20and%20Settings/ASUS/My. It is also the only antipsychotic agent that requires frequent white blood cell monitoring. Major depression and other mood disorders and substance abuse disorders are also risk factors for suicide.. e (Chapter 10) Among all the factors listed. detached loner with schizoid personality disorder.. hopelessness has been shown to be one of the most reliable indicators of long-term suicide P. schizophrenia (e) involves the persistence of psychotic symptoms and social or occupational dysfunction for at least 6 months.%20Folder/Blueprints%20Psychiatry/Answers. He overly depends on his mother to steer his life. and he lacks the grandiosity that would be seen in a person with narcissistic personality disorder. 38. Also. His self-esteem is not impaired. clozapine carries the highest risk of all the antipsychotics for this major adverse drug reaction. 40.Ovid: Blueprints Psychiatry pseudodementia. 39.htm (16 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ .141 risk. b (Chapter 5) This patient appears to have a profound yearning for connection and a dependent relationship with his elderly mother. Although many medications can cause granulocytopenia or agranulocytosis.

c (Chapter 16) This patient exhibits the classic symptoms of akathisia. Bipolar disorder requires the presence of at least one episode of mania and usually consists of cycles of mania and depression. decreased sleep. His denial of mood disturbance and lack of either prior hospitalizations or family history makes both bipolar disorder and cyclothymic disorder unlikely. pressured speech. 43. intrusive recollection of the trauma. but this patient does not display symptoms of mania (i. and efforts to avoid recollection of the trauma. a diagnosis of posttraumatic stress disorder is not made unless there is hyperarousal. They usually endorse an inner feeling of restlessness (often localized to the legs). but other symptoms of alcohol abuse would be present. such as dystonia (muscle spasm). a common side effect of antipsychotic medications. 42. especially auditory hallucinosis. restlessness. Paranoid personality disorder does not lead to the level of severe social and occupational dysfunction experienced by this patient. It is important to distinguish akathisia from restlessness and agitation caused by worsening psychosis or anxiety. Alcohol abuse can lead to psychosis. but this patient does not provide evidence of having major depression... etc. Psychosis is common in the manic phase of bipolar illness. Major depression may be associated with psychosis. a (Chapter 1) A diagnosis of schizophrenia requires a greater-than-6-month period of positive and negative symptoms of psychosis combined with social and occupational deterioration. the diagnosis becomes antisocial personality disorder.htm (17 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ .e. increased energy.Ovid: Blueprints Psychiatry 41. Patients with this side effect exhibit agitation.. file:///C|/Documents%20and%20Settings/ASUS/My. tardive dyskinesia (slow. A childhood history of severe neglect or abuse is not uncommon. e (Chapter 4) This patient exhibits a pervasive pattern of flagrant disregard for the rules and laws of society.). When conduct disorder behavior persists into adulthood. Other movement disorders.%20Folder/Blueprints%20Psychiatry/Answers. Despite the report of a childhood trauma. and pacing. This patient may have been diagnosed with conduct disorder in childhood.

Serotonin syndrome can cause tremor and confusion but not ataxia. restlessness. masked facies). Oxcarbazepine levels are also not as sensitive to levels of dehydration. Fluoxetine can cause nausea. but vocal and motor tics are not classic. Although oxcarbazepine toxicity can similarly result in ataxia and confusion. but they can develop into word tics. file:///C|/Documents%20and%20Settings/ASUS/My. Schizophrenia is not likely because this young man does not have psychotic symptoms. but the absence of fever and a normal serum creatine phosphokinase level make this diagnosis unlikely. insomnia. Signs of lithium toxicity. 44. Patients with neuroleptic malignant syndrome can present with agitation or motor excitability. Adolescent rebellion is a colloquial term for certain types of teenage behavior but does not explain vocal and motor tics.htm (18 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . 45. It is generally nontoxic even in overdose. its serum level can be affected by states of dehydration or renal insufficiency. including coarse tremor. A child suspected of having Tourette's disorder should have a careful medical and neurologic evaluation. and an electroencephalogram should be performed to assess for seizure disorder.%20Folder/Blueprints%20Psychiatry/Answers.. the vocal tics are grunts or barks. headache. are evident in this patient. Tourette's disorder is more common in young males (3:1 male-female ratio) and onset is usually in late adolescence. a (Chapters 13 and 16) Because lithium is renally cleared. it is not associated with coarse tremor or diarrhea. Substance abuse can produce a behavioral change in an individual. should always be ruled out in patients taking neuroleptics. ataxia. and anorgasmia. Wilson's disease and Huntington's disease both present with movement disturbance that could be confused with motor tics and therefore need to be ruled out. confusion. Sometimes. d (Chapter 7) Tourette's disorder is characterized by involuntary vocal and motor tics.Ovid: Blueprints Psychiatry involuntary muscle movements). or Parkinsonism (pill-rolling tremor. and diarrhea.. festinating gait. Conduct disorder is diagnosed when a child consistently violates the basic rights of others and ignores societal rules and norms.

e (Chapters 2. Individuals with obsessive-compulsive disorder have unreasonable obsessions and compulsions. a (Chapters 1 and 2) This patient presents with psychotic symptoms and agitation.%20Folder/Blueprints%20Psychiatry/Answers. Or. Patients with winter depression and atypical depression usually present with symptoms of decreased energy. Obtaining additional history is critical for properly evaluating this patient. increased appetite. file:///C|/Documents%20and%20Settings/ASUS/My. The patient may have alcohol dependence or abuse warranting a referral to Alcoholics Anonymous..Ovid: Blueprints Psychiatry P. collateral history of prior suicidal statements to family or friends is often uncovered. To accept the patient's assertion that the event was accidental would be inappropriate in the face of a life-threatening event. Patients often attempt suicide and then deny any intention to self-harm. This could be a so-called “first break” of schizophreniform disorder that may persist for the required 6 months to meet the criteria for schizophrenia. the diagnosis is uncertain. 5. It might be a manic episode with psychotic features in a patient with underlying bipolar disorder or schizoaffective disorder.142 46.htm (19 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . they are usually not agitated and do not have auditory hallucinations or thought disorder. A thyroid-stimulating hormone level might be appropriate if the patient is found to have depression. Intoxication with alcohol or other drugs is not uncommon. behavioral change consistent with a diagnosis of depression may be found. The psychosis may also be substance induced (e. but the available history does not support such a diagnosis at this point. Although patients with generalized anxiety disorder can present with restlessness or irritability. Denial or ambivalence regarding suicide attempts is frequently present. amphetamine-induced psychotic disorder). and increased sleep.g.. They also complain of psychomotor slowing.. In such cases. 47. A head CT does not appear clinically indicated unless one suspects head injury or intracranial process predisposing to self-injurious behavior. and 10) The described vignette is commonly seen in patients who attempt suicide. Until further history is obtained or future episodes are observed.

b (Chapters 2. An antidepressant would be indicated if additional history supported the diagnosis of major depression. he was restarted at his usual outpatient doses. Upon admission. Adding β-blockers and benzodiazepines is also helpful. 5. and 10) Forming a treatment alliance with the patient is the best path to obtaining additional information from him and helping him gain insight into his circumstances. A discussion of alcohol use and misuse is also important.Ovid: Blueprints Psychiatry 48. but these medications are so widely used and are prescribed by so many nonpsychiatric physicians. which presumably provide a therapeutic drug level when taken as scheduled. It is easily treatable by removing the offending agent in most cases. The patient likely was noncompliant with his medications as an outpatient. that this important side effect may be misdiagnosed. it leads to attempted or successful suicide. 49. Then. it is often unclear whether patients who attempt and then deny self-injury in the context of clear psychosocial stress and vocational and interpersonal difficulties are conscious of their suicidal intentions. b (Chapters 12 and 16) Akathisia is most commonly caused by antipsychotic medications. Denial of suicide attempts is quite common. Akathisia is profoundly distressing to some patients... 50. and in some cases. however. Akathisia produced by drugs in the selective serotonin-reuptake inhibitor class is less likely. The patient displays known symptoms consistent with carbamazepine toxicity. an file:///C|/Documents%20and%20Settings/ASUS/My. leading to reduced levels of mood stabilizer and a manic break. but the most urgent medical consideration at this point is suicidality.%20Folder/Blueprints%20Psychiatry/Answers. c (Chapters 13 and 16) The best explanation for the patient's condition at the moment is drug toxicity resulting from elevated carbamazepine levels. The clue to making the diagnosis rests with the sequence of events.htm (20 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . and the use of intoxicants before such attempts is also a common clinical scenario. particularly typical antipsychotics (neuroleptics). In the clinical setting.

Disorganized schizophrenia requires the presence of disorganized speech and behavior and inappropriate affect. a potent dopamine blocker. a (Chapter 1) Catatonic schizophrenia requires the presence of catatonic symptoms (motor and vocal changes). and difficulty initiating movements are all symptoms of Parkinson's disease. Quetiapine and clozapine both block dopamine receptors. Because low cerebral dopamine levels cause the disease. drugs that block dopamine receptors are most likely to mimic the disease. The “pill rolling” tremor.. such as macrolide antibiotics. Neither lorazepam nor benztropine block dopamine receptors. and gradual taper of benzodiazepines with improved symptoms of alcohol withdrawal are the appropriate treatment file:///C|/Documents%20and%20Settings/ASUS/My. We are not provided with the name of the drug.. Gradual taper of opiate pain medication with clinical improvement.htm (21 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . a drug-induced condition resembling Parkinson's disease. may inhibit the metabolism of medications metabolized by the liver's cytochrome P450 enzyme system. is most likely to cause the syndrome. e (Chapters 1 and 16) The patient has developed neuroleptic-induced Parkinsonism (also known as pseudo-Parkinsonism). 52. Haloperidol. 51. but it is important to remember that some antibiotics. but they only weakly block dopamine receptors and are less likely to cause pseudo-Parkinsonism. P. Undifferentiated schizophrenia is diagnosed when criteria are not met for another subtype.Ovid: Blueprints Psychiatry antibiotic is added.%20Folder/Blueprints%20Psychiatry/Answers.143 53. Residual schizophrenia is diagnosed when a patient who formerly had prominent positive symptoms of schizophrenia now has only residual negative symptoms or minor positive symptoms. festinating gait. a (Chapters 5 and 8) Continue the patient's current treatment regimen with downward adjustments in opiate and benzodiazepine dosing as pain and alcohol withdrawal symptoms subside.

54. Dialectical behavioral file:///C|/Documents%20and%20Settings/ASUS/My. as it may precipitate relapse or lead to oxazepam abuse or dependence in alcoholism. Duloxetine is an anti-depressant that might be used in treating the patient if he had major depression. 55. Acamprosate may work via numerous mechanisms. a (Chapters 5 and 15) Following successful alcohol detoxification. Electroconvulsive therapy can be used for both depression and mania but only in very severe cases that are refractory to other treatment. cognitive-behavioral therapy.Ovid: Blueprints Psychiatry at this point... Antidepressant medications may be useful in individuals with alcohol dependence and depression.or alcohol-dependent individuals in circumstances normally requiring treatment with opiate medications. or acamprosate alone would also be useful treatments but are not as effective individually as is combination therapy. combined treatment with Alcoholics Anonymous. Naltrexone.htm (22 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . The exact mechanism of naltrexone in preventing or lessening the severity of alcohol relapse is unknown but is presumably related to the action of naltrexone as a µ-opioid antagonist. Judicious use of opiates is necessary in many drug. The most appropriate treatment would be to stop fluoxetine and begin a mood stabilizer. cognitive-behavioral therapy. This is particularly common in postpartum patients treated with antidepressants. Benzodiazepines. and pharmacological management with naltrexone or acamprosate is indicated. including as a modulator of glutamate function. Oxazepam is used for acute detoxification for alcohol dependence but is contraindicated after detoxification. c (Chapters 2 and 12) The patient has likely developed substance-induced mania caused by fluoxetine treatment for her postpartum depression. Naltrexone is indicated for treating alcohol dependence but should not be given to a person taking opiates because it may precipitate severe withdrawal. attending Alcoholics Anonymous meetings. but we are not provided with evidence of depression in this patient. although potentially addictive. are used for the short-term treatment of alcohol withdrawal symptoms and should be slowly tapered to avoid precipitating a seizure or other severe withdrawal symptoms.%20Folder/Blueprints%20Psychiatry/Answers.

. but sexual side effects are common and could potentially further complicate his relationship with his wife. each of the other issues would be a valid concern. The dietary limitations of monoamine oxidase inhibitors would additionally limit their usefulness in a patient who works as a chef. however. Lithium is primarily an augmentative treatment for depression. 58. but it is indicated only for severe or refractory depression. Because of their primitive defenses. c (Chapters 4 and 17) The patient described has borderline personality disorder. If this were not an emergency situation. and performing a tracheotomy to stabilize the patient's airway would not require informed consent. Cognitive-behavioral therapy examines cognitive distortions and is primarily useful for depression and anxiety disorders. monoamine oxidase inhibitors are not used as first-line antidepressant treatments because of their requirement for dietary restrictions. Electroconvulsive therapy is not contraindicated 3 months after myocardial infarction. Commitment is not necessary or appropriate in this circumstance.%20Folder/Blueprints%20Psychiatry/Answers. Patients with borderline personality disorder often require adjunctive treatments for their substance abuse. e (Chapters 2 and 12) The patient's symptoms are consistent with major depression. mood disorders. Dialectical behavioral therapy was developed specifically for the treatment of borderline personality disorder.. they are generally not good candidates for long-term psychodynamic psychotherapy. Tricyclic antidepressants are very effective but are generally considered second-line antidepressants because of their toxicity and side-effect profiles. 57. Selective serotonin-reuptake inhibitors are a first-line choice for the treatment of depression. 56. Although very effective. committed patients also do not require informed consent for treatment. and other comorbidities. file:///C|/Documents%20and%20Settings/ASUS/My.Ovid: Blueprints Psychiatry therapy is indicated for borderline personality disorder. e (Chapters 1 and 18) This clinical scenario would be considered a true emergency.htm (23 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ .

with the P. Disulfiram serves to prevent alcohol ingestion through the fear of the consequences of its interaction with the metabolism of alcohol. b (Chapters 1. and dizziness. Serotonin syndrome can present similarly to neuroleptic malignant syndrome but usually has less muscular rigidity. Disulfiram blocks the oxidation of the acetaldehyde. It is most frequently seen during periods of dehydration or rapid escalation of dose. and 16) Neuroleptic malignant syndrome can occur at any time during the use of antipsychotic medications. Classical conditioning is learning in which a neutral stimulus is paired with a natural stimulus.. which leads to flushing. Behavioral management is also one of the mainstays of treatment.Ovid: Blueprints Psychiatry 59. vomiting. 61. which is generally managed with psychostimulants. 11. file:///C|/Documents%20and%20Settings/ASUS/My. These are sometimes avoided because of bizarre behavior or long-term physical effects such as weight loss and inhibited body growth. dry mouth.%20Folder/Blueprints%20Psychiatry/Answers. children can be treated with atomoxetine. nausea. sweating. headache.144 result that the previously neutral stimulus alone becomes capable of eliciting the same response as the natural stimulus. Akathisia consists of a subjective sensation of inner restlessness or a strong desire to move one's body.. Projection and regression are both defense mechanisms. Methylphenidate is the first-line agent followed by D-amphetamine. c (Chapter 17) Modeling is learning based on observing others and mimicking their actions. Dystonia is a neuroleptic-induced movement disorder characterized by muscle spasms. Operant conditioning is a form of learning in which environmental events influence the acquisition of new behaviors or the extinction of existing behaviors. 60.htm (24 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . Alternatively. c (Chapters 7 and 15) The child described in Question 59 meets the criteria for attention-deficit/hyperactivity disorder.

b (Chapter 12) The most common side effect of electroconvulsive therapy (ECT) is short-term memory loss and confusion. The patient does have symptoms consistent with hyperthyroidism. d (Chapters 1.Ovid: Blueprints Psychiatry 62. Benzodiazepines may be used also in the management of acute mania.htm (25 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . That his daughter has observed the patient to be despondent. A mood stabilizer or antipsychotic medication may be needed now or at a later point for symptom control but would not be started for the specified diagnoses until a definitive workup is completed. 2. however. Because the patient was found with a gun. Antidepressants should be used with caution because of the possibility of inducing mania or producing a more severe mania. Bilateral ECT is more effective than unilateral ECT but produces more cognitive side effects. 10. Therefore. b (Chapters 2. A person can have bereavement following the loss of a loved one. c (Chapters 2. The onset of bipolar disorder in someone of this age group with no prior psychiatric history is unlikely. and 8) This patient displays the key symptoms necessary for the diagnosis of an acute manic episode. and is denying file:///C|/Documents%20and%20Settings/ASUS/My. medical and neurological causes of the patient's behavioral change should be carefully assessed. An antidepressant would not help treat this symptom complex and might make the condition worse. Mood stabilizers and antipsychotic medications are the mainstays of maintenance therapy. 64. the lack of sleep and grooming. 12. but these symptoms are more consistent with major depression. and 13) The patient described meets probable criteria for bipolar disorder. and the apparent weight loss.%20Folder/Blueprints%20Psychiatry/Answers. but the treatment would not be to add more thyroid hormone. 63. ECT has some efficacy in refractory mania and in psychoses with prominent mood components or catatonia.. and 12) This patient appears to have major depression likely brought on by his wife's death. has severe symptoms. is suggestive of major depression. 65..

Multivitamins file:///C|/Documents%20and%20Settings/ASUS/My.%20Folder/Blueprints%20Psychiatry/Answers. Hopelessness about the future increases the risk of suicide. 67. Propanolol does not have a role as monotherapy in treating major depression and may exacerbate or cause symptoms of depression..Ovid: Blueprints Psychiatry illness. decreased sleep. but might worsen this patient's condition.htm (26 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . Mirtazapine is often used in elderly individuals and improves sleep and appetite. d (Chapters 2 and 10) The suicide rate in Caucasian males over age 65 is five times that of the general population. b (Chapters 2 and 12) Electroconvulsive therapy is an appropriate treatment option in an elderly individual with life-threatening depression. Cognitive-behavioral therapy is a useful treatment for mild-to-moderate depression but is not appropriate given the severity of this patient's symptoms (but might be an important therapy once he improves somewhat). d (Chapters 12 and 17) Appropriate initial therapy for this patient would include an antidepressant medication. and poor grooming are associated with major depression but have not been shown to be strong indicators for increased suicide risk. 68. Neurological consultation and nutritional therapy may be important components of this patient's management once he has been placed in a safe setting. also increase the risk of suicide. Decreasing the mirtazapine would not improve. 66.. Weight loss. it is more appropriate to admit the patient to a psychiatric hospital than to arrange for outpatient treatment. Valproate is a mood stabilizer medication most appropriate for treating mania in bipolar disorder. Dialectical behavioral psychotherapy has been demonstrated to be effective mainly in the treatment of borderline personality disorder. This patient does not display evidence of mania. Buspirone is sometimes used as an adjunct to antidepressant treatment but is approved for treating generalized anxiety disorder. Psychiatric disorders. especially major depression.

is associated with agitation. Schizophrenia. and other signs of paranoia would not be present.%20Folder/Blueprints%20Psychiatry/Answers. sedated condition.145 pain of some types but has not been demonstrated to be effective in severe depression. and psychomotor retardation. paranoia. or depression with psychosis) should all be carefully considered. Therefore. pressured speech. and REM sleep intrusions (experienced as sudden vivid dreams that may intrude into the waking state). Hypothyroidism generally presents with apathy. If experienced file:///C|/Documents%20and%20Settings/ASUS/My. Paranoia is also not usually a component of heroin intoxication. and agitation are not consistent with this condition. d (Chapter 1) Panic disorder with a panic attack might cause a disturbance in a public place. a condition characterized by daytime sleep attacks. Hyperthyroidism might mimic some of the patient's symptoms. if severe.htm (27 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . d (Chapters 9 and 15) The clinical history is most consistent with a diagnosis of narcolepsy. again. with decreased heart rate and respirations. cataplexy (sudden. pressured speech. Of note. the REM intrusions are called hypnagogic hallucinations. drug-induced paranoia. 70. such as pressured speech or agitation. depression. Attention-deficit/hyperactivity disorder might present with excessive motor activity but. reversible medical causes. and other psychiatric conditions (such as schizoaffective disorder.. The time course of the patient's illness.. bilateral loss of skeletal muscle tone). this is the best diagnostic choice among the provided options.Ovid: Blueprints Psychiatry may be important for general good health but do not treat depression per se. reversible. there is not sufficient evidence provided in this vignette to make a formal diagnosis of schizophrenia. 69. Gabapentin is used for seizure disorders and neuropathic P. If experienced at sleep onset. and disheveled appearance. mania with psychosis. paranoid subtype. Heroin intoxication usually presents with a quiet. paranoia. but odd accusations. sleep paralysis (temporary paralysis upon awakening from sleep).

72. Akathisia resulting from medication administration. The elevations in liver enzymes coupled with a relative pancytopenia and a history of liver problems is consistent with a diagnosis of alcohol dependence. especially following traumatic injury.htm (28 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ .. is quite sedating and would likely exacerbate daytime sleepiness. but antisocial personality disorder is not directly associated with confusion. and would be uncommon in this age group. A psychotic disorder can be associated with agitation. Antisocial personality disorder is associated with traits that might include agitation or threatening behavior. is not part of the patient's prior history. The patient's drop attacks with retained consciousness do not suggest a diagnosis of seizure disorder. although other medical causes of these findings should be ruled out. is a common cause of agitation but not confusion in the intensive care unit setting. is the presence of alcohol withdrawal delirium potentially complicated by Wernicke's encephalopathy. the REM intrusions are called hypnopompic hallucinations. c (Chapters 5 and 8) Relatively acute-onset agitation and confusion in the intensive care unit setting is commonly caused by delirium.. Continuous positive airway pressure at night to improve abnormal breathing is an appropriate treatment for breathing-related sleep disorder. Valproic acid is used in the treatment of bipolar disorder and seizure disorder but not for narcolepsy. Opiates and antibiotics are not likely to produce akathisia. Administration of intravenous thiamine is a critical treatment to prevent the development of irreversible brain damage as seen in file:///C|/Documents%20and%20Settings/ASUS/My.Ovid: Blueprints Psychiatry at awakening. d (Chapters 5 and 8) An all-too-common cause of delirium in the intensive care unit setting. Dementia is a risk factor for the development of delirium. Administration of Ambien at bedtime is an appropriate short-term treatment for insomnia.%20Folder/Blueprints%20Psychiatry/Answers. Sleepiness in the absence of mood symptoms does not suggest a diagnosis of bipolar disorder. Olanzapine. especially administration of typical antipsychotics (neuroleptics). 71. but the onset of dementia is usually quite gradual. Modafinil is an approved treatment for narcolepsy and enhances daytime alertness. an atypical antipsychotic medication. but no history of psychotic symptoms is provided.

Ovid: Blueprints Psychiatry Wernicke's encephalopathy. along with supplementation of magnesium. e (Chapter 5) Naltrexone is an opiate antagonist medication that is approved for use in alcohol dependence. but it does not treat autonomic hyperarousal. is often an important supportive treatment in alcohol withdrawal but does not treat the life-threatening symptoms of seizure and autonomic hyperarousal. Propanolol alone or clonidine alone might reduce aspects of sympathetic activation but would actually mask the severity of the withdrawal and would not help to prevent seizure. The treatment of choice is a benzodiazepine medication to prevent further deterioration and prevent seizure. Buspirone is a medication approved for generalized anxiety. Naltrexone as a pharmacological treatment should be combined with psychosocial treatments such as attendance at Alcoholics Anonymous and participation in psychotherapy. blood pressure..htm (29 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . 74.. but it does help reduce alcohol intake.%20Folder/Blueprints%20Psychiatry/Answers. Intravenous hydration.146 Naltrexone should not be used in patients who continue to take opiate pain relievers because the medication will precipitate acute opiate withdrawal. The patient has elevated heart rate. the primary diagnostic consideration is alcohol withdrawal delirium. Antidepressant medications may be important adjunct therapy in individuals who have depression that persists after file:///C|/Documents%20and%20Settings/ASUS/My. and thiamine. folate. Naltrexone does not treat alcohol withdrawal. and body temperature symptoms consistent with autonomic hyperarousal. Alcohol withdrawal delirium is a life-threatening complication of untreated alcohol withdrawal that typically starts 48 to 72 hours after abrupt cessation of alcohol intake in alcohol-dependent individuals. 73. d (Chapter 5) At this point. P. Benzodiazepine medications are indicated in the treatment of alcohol withdrawal but have a high risk of abuse and are generally not indicated for postdetoxification treatment.

e (Chapter 2) The rapid cycling specifier can be applied to bipolar I or bipolar II disorder. 76.. Although patients with Asperger's disorder may appear to avoid social contact. stages 3 and 4) is decreased in depression. There are also rapid-eye-movement (REM) sleep alterations including increased time spent in REM and earlier onset of REM in the sleep cycle (decreased latency to REM). 75. or hypomanic file:///C|/Documents%20and%20Settings/ASUS/My. Anxiety should always be ruled out. Asperger's disorder tends to be diagnosed later than autism. mixed. a (Chapter 7) This patient exhibits the common features of a person with a developmental disability..%20Folder/Blueprints%20Psychiatry/Answers. whereas in autism. as should posttraumatic stress disorder. language is often severely impaired.htm (30 of 40) [30/01/2009 06:32:33 ‫]ﻡ‬ . suggesting that he no longer requires opiates for acute pain relief.Ovid: Blueprints Psychiatry alcohol detoxification but are not generally indicated for treating alcohol abuse or dependence. and IQ is largely preserved in Asperger's disorder but often impaired in autism. An opiate analgesic medication is not indicated because the patient has already been tapered from opiate analgesics. It is defined as at least four episodes of a mood disturbance in the previous 12 months that meet criteria for a major depressive. In Asperger's disorder. 77. Children with either condition can be quite withdrawn and socially awkward. language function is preserved. but many individuals in acute alcohol withdrawal have markedly elevated blood pressure that normalizes after detoxification. An antihypertensive medication might be appropriate if a patient has persistently elevated blood pressure following alcohol detoxification. The main distinguishing feature is the presence or absence of language difficulties. d (Chapter 2) Objective evidence from sleep studies conducted on people with depression has revealed that deep sleep (delta sleep. this is secondary to the recurrent experiences of social rejection that are common for children with Asperger's disorder. The social difficulties and getting lost in small details while missing the big picture are common manifestations of either autism or Asperger's disorder. manic.

Patients on carbamazepine need to have their complete blood count monitored because of rare side effects including agranulocytosis..%20Folder/Blueprints%20Psychiatry/Answers.. or voluntary assumption of inappropriate or bizarre postures. mixed. 79. checking. and basal ganglia (especially caudate nucleus) dysfunction in the pathogenesis of this disorder. manic. cingulate gyrus. there has to have been a regular temporal relationship between the onset of the major depressive episode and a particular time of year. Obsessions may consist of aggressive thoughts and impulses.htm (31 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . 78. When using lithium. fears of contamination by germs or dirt. or hypomanic episode if the patient demonstrates at least two of the following signs: motoric immobility. b (Chapter 13) The medication is valproate. In order to diagnose a patient with the seasonal pattern specifier. hypersomnia. pancytopenia. A specification of catatonic features can be applied to a current major depressive. Serotonin is also believed to play a file:///C|/Documents%20and%20Settings/ASUS/My. or leaden paralysis during their mood episode. mutism. Compulsions such as washing. Psychiatrists typically do not regularly monitor blood levels of lamotrigine and gabapentin.Ovid: Blueprints Psychiatry episode. excessive motor activity. or fears of harm befalling someone. This anticonvulsant mood stabilizer is more effective than lithium for the rapid-cycling and mixed variants of bipolar disorder. or counting are rituals with the purpose of neutralizing or reversing the fears. it is important to monitor thyroid and kidney function. This patient had depressive episodes in both winter and fall. d (Chapter 3) Obsessive-compulsive disorder (OCD) is one of the more disabling and potentially chronic anxiety disorders. and aplastic anemia. Postpartum refers to the onset of an episode within 4 weeks postpartum. You must check the patient's liver function tests because of the rare but fatal side effect of hepatotoxicity. It is characterized by anxiety-provoking intrusive thoughts and repetitive behaviors. Atypical features refer to patients who demonstrate mood reactivity and significant weight gain. echolalia. Functional imaging studies over the past several years have implicated prefrontal cortex.

fears of contamination by germs or dirt.Ovid: Blueprints Psychiatry primary role in OCD. Individuals with schizoid personality disorder lack a fundamental capacity for intimacy. Selective serotonin reuptake inhibitors. and mental and interpersonal control.%20Folder/Blueprints%20Psychiatry/Answers. This pattern begins by early adulthood and is present in a variety of contexts. Despite the similarity in names. e (Chapter 18) The three elements commonly recognized in informed consent include information. has been most strongly implicated in the pathogenesis and treatment of schizophrenia. GABA dysfunction is implicated in anxiety disorders. 81. are first-line treatment for OCD. e (Chapter 4) The essential feature of obsessive-compulsive personality disorder (OCPD) is a preoccupation with orderliness. They are exploitive and rarely experience remorse. however. or counting are rituals with the purpose of neutralizing or reversing the fears. such as fluvoxamine. at the P. Information is the content of the proposed treatment and the alternatives to treatment. Dopamine may play a role in depression and some antidepressant agents. Norepinephrine may play a role in the pathogenesis of major depression and other psychiatric conditions. and efficiency. obsessive-compulsive disorder (OCD) is usually easily distinguished from obsessive compulsive personality disorder by the presence of obsessions and compulsions as well as based on symptom severity.147 expense of flexibility. capacity. perfectionism. or fears of harm befalling someone... Compulsions such as washing. Individuals with antisocial personality disorder repetitively disregard the rules and laws of society. and consent. Dopamine. and GABA agonists are widely used to treat some anxiety disorders.htm (32 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . 80. People with OCPD are usually self-critical. such as bupropion. including schizophrenia. Glutamate dysregulation has been implicated in many conditions. checking. may modify the dopaminergic system. openness. including potential effects file:///C|/Documents%20and%20Settings/ASUS/My. whereas those with narcissistic personality disorder are more likely to believe that they have achieved perfection. Obsessions may consist of aggressive thoughts and impulses.

must not involve subtle or overt coercion. and reasoning to fully demonstrate all elements of capacity. file:///C|/Documents%20and%20Settings/ASUS/My. Negligence is an element of medical malpractice. cardiac arrhythmia. it is important for practicing physicians to know the rules in their jurisdiction. An abdominal ultrasound is not likely to be of use unless the patient complains of abdominal pain or other signs suggesting splenic infarction or abdominal aneurysm rupture. reason. Ruling out drugs of abuse as a cause of this event is critical to future treatment and monitoring of this patient.%20Folder/Blueprints%20Psychiatry/Answers.Ovid: Blueprints Psychiatry of failing to treat.htm (33 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . 83. An electroencephalogram is unlikely to be of use in an alert patient who has no evidence of altered mental status or headache. c (Chapter 5) The patient's symptom complex is consistent with that of intoxication with psychostimulant drugs such as cocaine.. The patient likely has myocardial ischemia caused by cocaine-induced coronary artery vasospasm.. Griswold v. it is most important to treat the patient as any other patient with an acute myocardial infarction or acute myocardial ischemia depending on the electrocardiogram and other findings. namely. Liver function tests might be of use in such a patient if there are risk factors for alcoholic hepatitis or viral hepatitis. 82. This patient has expressed a choice but would need to show evidence of understanding. however. In a patient who presents with this symptom complex. The M'Naghten rule refers to the insanity defense. or stroke. The duty to warn is based on initial rulings by the California Supreme Court and is not based on Swedish Common Law. Hematocrit will not aid in the immediate diagnosis of the patient's condition. a (Chapter 18) The Tarasoff decisions held that therapists have a reasonable duty to warn potential victims of threats made by patients in treatment. The patient is at risk for myocardial infarction. Connecticut is not pertinent. Although there are many different legal interpretations of this decision (also called the duty to warn or protect). Capacity requires that a person possess the ability to understand. Consent must be given voluntarily. and express a choice. appreciate. appreciation.

but this is common among cocaine users in the absence of antisocial personality disorder. but the current evidence does not yet support that diagnosis. e (Chapters 3 and 14) file:///C|/Documents%20and%20Settings/ASUS/My. 86.Ovid: Blueprints Psychiatry but they are not critical to the current diagnosis. This patient may have engaged in illegal activity. repeated unintended excessive use. the only diagnosis that can be made with confidence is that of myocardial infarction.htm (34 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ .addicted or drug-abusing individuals and is not necessarily a symptom of malingering. 85. 84.. The patient quite likely has cocaine abuse or cocaine dependence. To make a diagnosis of cocaine dependence. excessive time spent trying to obtain the substance. Denial of drug use is remarkably common among drug. We do not yet have evidence for the other criteria. and he would therefore meet the last criterion (awareness of physical difficulties). Damage to these structures is thought to be caused by thiamine deficiency. occupational. fornix. Polydrug abuse or at least polydrug exposure might also be found in this patient. caudate and putamen. b (Chapters 5 and 8) Alcohol-induced persistent amnestic disorder (Korsakoff's psychosis) is associated with damage to the hippocampus. and continued use despite awareness that cocaine is causing psychological or physical difficulties. Because this patient presented on multiple occasions to the emergency ward with chest pain following cocaine use. and mammillary bodies. and cerebellum are not brain regions associated with amnestic disorder in alcoholism. cocaine-related reductions in social.. The brain stem and frontal lobes. d (Chapter 5) At present. he is probably aware of the association between use of the drug and chest pain. however. one would need to know that the patient had at least three symptoms consistent with tolerance. withdrawal. thalamus and cingulate gyrus. Malingering is diagnosed when a person deceives to obtain secondary gain. Antisocial personality disorder requires a consistent and sustained pattern of disregard for social rules. or recreational activities. persistent failed efforts to cut down.%20Folder/Blueprints%20Psychiatry/Answers.

. Finally.. Between the ages of 5 and 13. ego integrity versus despair involves late-life acceptance of one's place in the life cycle versus regret of unfulfilled earlier life desires. The father is teaching and guiding his son in the sport. Melatonin is associated with sleep disturbances. Anxiety disorders have been most strongly associated with alterations in the inhibitory neurotransmitter GABA. the child is struggling with what his performance on the soccer field implies about his general worthiness.htm (35 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . Intimacy versus isolation. Initiative versus guilt precedes identity versus inferiority at ages 3 to 5 and involves the feelings of guilt that ensue when a child first has enough autonomy to explore the world including things that the parents may find disturbing. d (Chapter 17) The boy is struggling with Erikson's life cycle known as industry versus inferiority. Serotonin and norepinephrine are also implicated in the P. answer a. she file:///C|/Documents%20and%20Settings/ASUS/My. Identity versus role confusion occurs just after identity versus inferiority and corresponds to adolescence.148 pathophysiology of these conditions. Although many clinicians may find themselves feeling annoyed with her preoccupation. The patient does not gain satisfaction from showing her body to others as in exhibitionism. a (Chapter 9) The patient holds a perception that her nose is crooked. Caregivers provide for a sense of mastery by teaching and giving feedback. Substance P and enkephalin are most notably associated with pain. 88. 87. occurs later in development in young adulthood. Glycine is associated with inhibitory transmission in the spinal cord. This is body dysmorphic disorder. that does not appear to be true. In this case. children struggle with developing a sense of self based on the things that they create. which is undoubtedly promoting the son's psychological development. and therefore ugly. She is extremely preoccupied with this perceived problem in her physical appearance to the point that she has sought surgical remediation.Ovid: Blueprints Psychiatry The patient has the classic symptoms of panic disorder.%20Folder/Blueprints%20Psychiatry/Answers.

b (Chapter 8) Although there can be a large amount of overlap of symptoms between Alzheimer's disease. the differences are readily apparent on pathologic review.%20Folder/Blueprints%20Psychiatry/Answers. which suggests social phobia.Ovid: Blueprints Psychiatry does not have the other clinically troubling features of a person with borderline personality disorder. losing weight. Pick's disease is marked by “Pick bodies. Imaging studies and presentation help make the diagnosis. Finally... subcortical small vessel disease. dialectical behavior therapy is another therapy that focuses on present-day file:///C|/Documents%20and%20Settings/ASUS/My. to guide the treatment. but her feelings are only in relation to her perception that her nose is crooked. Pick's disease. Behavior therapy uses behavioral principles of reinforcement and aversion to effect specific behavioral changes (e. people with posttraumatic stress disorder have anxiety and present in emergency rooms with nonspecific distress but do not have a preoccupation with a particular part of their body. The focus on relationships indicates that the therapist may have been using object-relations theory. and vascular dementia.. This is not seen in Alzheimer's disease. Pick's disease is generally characterized by an onset of personality change and a decline in function at work and home. a common form of psychoanalysis. 90. the focus would have been on more present-day thoughts and their impact on feelings. Creutzfeldt-Jakob's disease presents with the clinical triad of myoclonus. dementia. If it were cognitive-behavioral therapy. She does feel scrutinized in public places. Interpersonal therapy is a short-term therapy that focuses on specific aspects of present-day relationships. The focus on early childhood and the multiple sessions per week are common features of this type of therapy. At autopsy. and abnormal electroencephalogram results. Huntington's chorea generally presents with a movement disorder followed by emotional lability or depression and then dementia. Pick's disease is also typically restricted to the frontal and anterior temporal lobes. Vascular dementia is more commonly characterized by either multiple cortical infarcts.htm (36 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . quitting smoking). b (Chapter 17) The patient was likely undergoing some kind of psychoanalytic psychotherapy. Spongiform encephalopathy is present at autopsy.g. 89. Finally. which is characterized by the plaques and tangles.” and neurons have a ballooned appearance. or strategically placed infarcts.

Buspirone is not a benzodiazepine and is not used for alcohol detoxification. 91. Clonazepam is a long-acting benzodiazepine. P. d (Chapter 15) The medication is probably naltrexone. including cigarette smoking. and temazepam are benzodiazepines metabolized primarily by conjugation and do not have active metabolizes. Zolpidem is a non-benzodiazepine sleep aid. a (Chapter 14) Lorazepam. Patients with these risk factors often show nonspecific brain white matter disease on MRI and should have slowed progression of dementia if treated for the underlying risk factors.. b (Chapter 8) The patient has multiple risk factors for vascular-related dementia. but it does not have long-acting metabolites.%20Folder/Blueprints%20Psychiatry/Answers. It also does not cause illness when alcohol is consumed with it as does disulfiram (Antabuse). buspirone is a non-benzodiazepine anxiolytic.Ovid: Blueprints Psychiatry thoughts and feelings to help patients with borderline personality disorder to manage intolerable feelings and decrease self-destructive behaviors.149 hypertension. hypercholesterolemia.. type 2 diabetes mellitus. oxazepam. and coronary artery disease. and metoclopramide is a medication that is approved for gastroesophageal reflux disease and is also used off-label for migraines. 92. Naltrexone has been shown to decrease frequency and intensity of alcoholic relapse. 93.htm (37 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . HIV is associated file:///C|/Documents%20and%20Settings/ASUS/My. Creutzfeldt-Jakob disease is prion-linked. these two medications are prone to accumulate in individuals with impaired hepatic metabolism and may cause benzodiazepine toxicity. Parkinson's disease is caused by degeneration in monoamine and other brain neurons. Thus. Huntington's disease is an autosomal dominant inheritance. Diazepam and chlordiazepoxide are metabolized mainly by glucuronidation and have long-acting metabolites.

nightmares. and difficulty concentrating. Withdrawal from crack cocaine and crystal methamphetamine is generally characterized by fatigue. fatigue. which consists of sexual fantasies and the urge to have sex. b (Chapter 9) The sexual response cycle is divided into four stages: (1) Desire is the initial stage of sexual response.Ovid: Blueprints Psychiatry with exposure to the HIV virus. The patient's syndrome complex is consistent with sleep apnea syndrome. 94. (4) Resolution is the physiologic relaxation associated with a sense of well being.. the patient can appear psychotic during intoxication with these agents.htm (38 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . sweating. Nicotine withdrawal is characterized by irritability. 96. d (Chapter 5) Barbiturate withdrawal can be fairly dangerous and can include hyperpyrexia. insomnia. a type of breathing-related sleep dysfunction consisting of recurrent episodes of apnea while sleeping. and potentially death. muscle cramps. 97. Occasionally.. e (Chapter 9) Breathing-related sleep disorder is a condition characterized by disordered breathing during sleep that results in frequent awakening and fragmentation of nighttime sleep with resultant daytime sleepiness. and hunger. In males. depression. usually associated with ejaculation in males. crystal methamphetamine. headache. there is usually a refractory period for further excitement and orgasm. 95. and marijuana is generally self-limited. The presence of loud snoring and choking or gasping during sleep is a cardinal sign of this condition. (2) Excitement consists of physiologic arousal and feeling of sexual pleasure. Withdrawal from crack cocaine. (3) Orgasm is the peaking of sexual pleasure. seizure. Plateau is not a phase of the sexual response cycle.%20Folder/Blueprints%20Psychiatry/Answers. c (Chapter 5) file:///C|/Documents%20and%20Settings/ASUS/My.

. and reduces the spread of HIV. sexual arousal is derived from nonliving objects. When buprenorphine is combined with naloxone. morphine. however. and hydromorphone are prescription analgesics that are often abused. 98. a partial opioid agonist. Acamprosate is a glutamate receptor modulator used for the maintenance of alcohol abstinence. Methadone is a long-acting opiate agonist used in methadone maintenance treatment for opiate dependence. Buprenorphine. It involves administration of a single daily dose of the long-acting opioid in a controlled setting along with provision of counseling and social services. Flumazenil is a benzodiazepine receptor antagonist. In fetishism. In pedophilia. buprenorphine does have the potential to be abused as an injectable agent. hydrocodone. c (Chapter 9) The essential features of a paraphilia are recurrent. sexual excitement is derived in fantasy or behavior involving file:///C|/Documents%20and%20Settings/ASUS/My. Morphine. When used alone.Ovid: Blueprints Psychiatry Methadone maintenance is a method of long-term treatment of illicit opioid abuse (primarily heroin but also abuse of illicitly obtained prescription opioids). and hydromorphone are opioids but are not used as maintenance therapy to treat opioid dependence. or behaviors generally involving (1) nonhuman objects. Heroin.. supportive services are vital to the success of a methadone maintenance program. sexual urges. or (3) children or other nonconsenting persons that occur over a period of at least 6 months. Exhibitionism is a paraphilia in which a person derives sexual excitement from exposing one's genitals to a stranger. it will cause withdrawal when given parenterally. Methadone maintenance reduces and often eliminates use of nonprescribed opioids. intense sexually arousing fantasies.%20Folder/Blueprints%20Psychiatry/Answers. hydrocodone. Naloxone is an opioid antagonist that has poor oral absorption. c (Chapter 5) Suboxone is the brand name for the combination of buprenorphine with naloxone. 99. Frotteurism is sexual excitement derived by rubbing one's genitals against or by sexually touching a nonconsenting stranger. reduces illicit opioid use with long-term therapy. decreases criminal activity associated with illicit drug use.htm (39 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . (2) the suffering or humiliation of oneself or one's partner.

double vision. the diagnosis is made if the person has acted on these urges or if the urges or sexual fantasies cause marked distress or interpersonal difficulty. b (Chapter 9) The essential feature of conversion disorder is the presence of symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. sexual symptoms. The symptoms are not intentionally produced as in factitious disorder. and pseudoneurological symptoms that are not caused by a medical illness.Ovid: Blueprints Psychiatry sex with prepubescent children.150 or deficits include loss of touch or pain sensation. and urinary retention. Sensory symptoms P. Conversion symptoms are related to voluntary motor or sensory functioning and are thus referred to as “pseudoneurological. and hallucinations. gastrointestinal disturbance. blindness.%20Folder/Blueprints%20Psychiatry/Answers.. Somatization disorder is a type of somatoform disorder in which patients have multiple chronic medical complaints that include pain. difficulty swallowing or a sensation of a lump in the throat.. sexual excitement is derived from fantasy or behavior involving the observation of unsuspecting people undressing.” Motor symptoms or deficits include impaired coordination or balance.htm (40 of 40) [30/01/2009 06:32:34 ‫]ﻡ‬ . naked. A diagnosis of conversion disorder should be made only after a thorough medical investigation has been performed to rule out a neurological or general medical condition. deafness. In voyeurism. Hypochondriasis is a somatoform disorder involving preoccupation with having a serious disease that appears to be based on a misinterpretation of bodily function and sensations. file:///C|/Documents%20and%20Settings/ASUS/My. Body dysmorphic disorder is a somatoform disorder characterized by excessive concern regarding an imagined or perceived defect in appearance. There are typically psychological factors or stressors associated with the symptom or deficit. For paraphilias. or having sex. paralysis or localized weakness. 100. aphonia.

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